197609720-1-12-2024-31-AS-TAGD-CZQM2T-20240122081402

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609720
Report Date: 01/12/2024
Date Signed: 01/12/2024 04:16:56 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/21/2023 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20231221093054

FACILITY NAME:	HAVENS AT ANTELOPE VALLEY ASSISTED LIVING, THE		FACILITY NUMBER:	197609720
ADMINISTRATOR:	MINDY MENDOZA-PERRY		FACILITY TYPE:	740
ADDRESS:	43051 15TH SREET WEST		TELEPHONE:	(661) 723-8525
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY:	115	CENSUS: 91	DATE:	01/12/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Karen Marin		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff pushed resident(s)
Staff do not ensure resident is bathed
Staff do not clean resident rooms
Staff do not provide laundry service to resident(s)

INVESTIGATION FINDINGS:

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On 1/12/2024 Licensing Program Analyst (LPA) Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth was met by the Administrator and LPA explained the purpose of this visit was to deliver findings for this complaint.
The investigation consisted of the following: On 05/03/2023, LPA Spaeth conducted a 10-day visit and requested the resident roster, staff roster/phone numbers, and a list of residents who receive assistance with showering. LPA received the documentation request and LPA interviewed nine residents and nine staff members. During today’s visit, LPA interviewed two residents, two staff members, two managers and three resident family members.

It was alleged that residents have been pushed by staff members and staff members have pushed each other. It was alleged that the incidents have been communicated to management but management has not addressed the incidents because the manager(s) have become upset. Also, it was alleged that some

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20231221093054

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HAVENS AT ANTELOPE VALLEY ASSISTED LIVING, THE	FACILITY NUMBER: 197609720
	VISIT DATE: 01/12/2024

NARRATIVE

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residents have asked some staff members not to enter their room. LPA interviewed 12 out of 91 residents and 12 out of 47 staff members. The residents unanimously stated staff members have not pushed them, have not witnessed a staff member push another resident, have not witnessed a staff member push another staff member, and residents have not asked some staff members not to enter their room.
The 12 staff members stated they have not pushed a resident, and they have not witnessed another staff member push a resident. The two managers confirmed this type of behavior has not been observed and has not been reported to the managers. The allegation, staff pushed resident(s) is unsubstantiated.

It was alleged that residents are not receiving the proper care such as showering because some employees are related to other employees. Twelve out of the 91 residents receive assistance with showering. Six out of the 12 residents who receive assistance with showering stated the staff assist them twice a week. The six residents stated the staff never miss assisting them. The 12 out of the 47 staff members interviewed stated they observe all other staff members performing their jobs and stated the management team treat all staff members the same. LPA interviewed three family members who stated there are no issues with residents receiving assistance with showering. The two managers stated have not received complaints from residents or family members regarding this allegation. Therefore, the allegation staff do not ensure resident is bathed is unsubstantiated.

It was alleged that residents’ rooms have not been cleaned by staff members. Twelve out of the 91 residents unanimously stated staff never miss cleaning their room. The 12 out of the 47 staff members interviewed stated the residents and their family members have not complained about the cleaning services provided by the housekeeping staff. Therefore, the allegation staff do not clean resident rooms is unsubstantiated.

It was alleged that residents’ laundering had not been washed by staff members. Twelve out of the 91 residents unanimously stated staff do launder their clothing and bedding. The 12 out of the 47 staff members interviewed stated the residents and their family members have not complained about the laundering service. Therefore, the allegation staff do not provide laundry service to resident(s) is unsubstantiated.

An exit interview was conducted, and a hard copy of this report was given.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024

LIC9099 (FAS) - (06/04)

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