197609720-5-2-2024-31-AS-NGID-D58UXG-20240513155817

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609720
Report Date: 05/02/2024
Date Signed: 05/02/2024 12:13:25 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/12/2024 and conducted by Evaluator Angela Panushkina

COMPLAINT CONTROL NUMBER: 31-AS-20240412163855

FACILITY NAME:	HAVENS AT ANTELOPE VALLEY ASSISTED LIVING, THE		FACILITY NUMBER:	197609720
ADMINISTRATOR:	KAREN MARIN		FACILITY TYPE:	740
ADDRESS:	43051 15TH SREET WEST		TELEPHONE:	(661) 723-8525
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY:	115	CENSUS: 90	DATE:	05/02/2024
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Blaine Lyons, Regional Operations Specialist		TIME COMPLETED:	12:35 PM

ALLEGATION(S):

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Staff did not accurately assess resident's needs.

INVESTIGATION FINDINGS:

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At 11:50am, Licensing Program Analyst (LPA) Angela Panushkina conducted a subsequent visit to deliver final findings.LPA met with the Regional for Health and Wellness and Regional Operations Specialist and explained the reason for the visit.

During the initial visit conducted by LPAs Panushkina and Khurshudyan on 04/16/24, interviews and record review were made. At 10:45am, LPAs requested resident and staff roster and copies of pertinent information which include, but not limited to Admission Agreement, Pre-Admission Appraisal, Physician’s Report, Appraisal Needs and Services Plan, etc., relevant to the investigation. At approximately 10:55am, LPAs conducted a physical plant tour, to ensure health and safety of the residents are protected. Between 11:00am – 12:40pm, LPAs conducted an interviewed with the Community Sales Director, Regional for Health and Wellness, three (3) staff members, eight (8) out of ten (10) residents and Director of Nurses from the Hospice agency.
Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024

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-20240412163855

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: HAVENS AT ANTELOPE VALLEY ASSISTED LIVING, THE	FACILITY NUMBER: 197609720
	VISIT DATE: 05/02/2024

NARRATIVE

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It was reported that the staff did not accurately assess R1, and R1 was inappropriately placed in the Assisted Living Unit instead of Memory Care Unit. To investigate this allegation, LPAs conducted an interview with the Community Sales Director and Regional Vice President for Health and Wellness and were informed that R1’s Physician’s Report was complete prior to R1’s admission, and based on the information provided on the form the facility placed R1 in an Assisted Living Unit. In addition, interview with the Director of Nurses (DON) from R1’s Hospice agency revealed that although R1 cannot leave the facility unassisted, R1 is still alert, oriented and does not require to be placed in a Memory Care Unit at this time.

During today's visit, LPA an additional information was provided to LPA. Regional for Health and Wellness informed LPA that R1 no longer resides at this facility as of 04/16/2024. Based on interviews and record reviews this allegation is deemed Unsubstantiated.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024

LIC9099 (FAS) - (06/04)

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