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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609720
Report Date: 11/05/2021
Date Signed: 11/05/2021 01:17:45 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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, THEFACILITY NUMBER:
197609720
ADMINISTRATOR:BROCK, FREDAFACILITY TYPE:
740
ADDRESS:43051 15TH SREET WESTTELEPHONE:
(661) 723-8525
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:115CENSUS: 76DATE:
11/05/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Autumn Roberts-RodriguezTIME COMPLETED:
01:15 PM
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LPA Spaeth made an unannounced visit to the facility and was greeted by Autumn Roberts-Rodriguez, Assistant Executive Director. LPA stated the purpose of the visit was the investigation of an incident report regarding the personal rights of a resident.

At 11:00 am, LPA Spaeth was escorted by Assistant Executive Director for a tour of the facility. LPA viewed the kitchen and observed kitchen staff were preparing the noon meal and were wearing masks. LPA observed an adequate supply of fresh fruits/vegetables and dairy products in the walk in refrigerator. The freezer also contained frozen meats and the pantry was stocked with canned goods.

At 11:10 am LPA observed the first floor public bathrooms and staff bathrooms all contained wash your hands sign, hand soap, and paper towels. At 11:20 am, LPA interviewed R1 and observed the one bedroom apartment was thoroughly furnished with a kitchen, bed, linens, and adequate lighting. While touring the first and second floors, LPA observed the entire facility was neat and clean.

LPA Spaeth interviewed staff member (S1) from 11:25 am until 11:50 am. LPA reviewed resident records from 12:00 pm until 12:15 pm. LPA Spaeth also interviewed the Assistant Executive Director from 1:00 pm until 1:00 pm.

Further investigation regarding the incident will need to be completed. There are no deficiencies to report at this time. Exit interview was conducted, appeal rights discussed and a copy of the signed report was given to the Assistant Executive Director.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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