197609720-3-16-2023-31-AS-MSPH-CPYTV5-20230316150323

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609720
Report Date: 03/16/2023
Date Signed: 03/16/2023 03:03:31 PM

Document Has Been Signed on 03/16/2023 03:03 PM - It Cannot Be Edited

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, 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: 73	DATE:	03/16/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Mindy Mendoza-Perry		TIME COMPLETED:	03:00 PM

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LPA Spaeth conducted an unannounced visit and was greeted by the Administrator. LPA Spaeth stated the purpose of the visit was to tour the memory care renovation section.

LPA received an email as of 3/15/2023 from the Los Angeles Fire Department, Fire Inspector, Randy Frantz. Inspector Frantz included the Fire Safety Inspection Request dated 3/15/2023 which states fire clearance was granted.

Administrator confirmed there are eight (8) private rooms and five companion suites. The total census for this section is eighteen (18) potential residents. Administrator stated there will be one caregiver and one med tech who will also work as a caregiver.

LPA and Administrator toured the memory care wing from 1:10 pm until 1:35 pm.

Delayed Egress Keypad locations

LPA observed there are seven keypads located throughout the memory care section.

Main entrance into the wing - there is one entry for visitors which contained a keypad located outside the door. The Administrator entered the code and both parties walked into the wing. The Administrator stated each visitor will be personally escorted to the wing and the caregiver will enter the pass code.

Exit out of the wing - Upon entering through the door, LPA observed a keypad inside the wing at the wing entrance and the Administrator stated caregivers will escort each visitor out of the wing by using the keypad.

Exit Door at the back of the wing - LPA also observed a keypad at an exit door that leads to the outside section of the facility. This is the fire escape door.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/16/2023

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Exit Door to the outside area for Residents – LPA observed a keypad which leads to the outside sitting area for memory care residents. Administrator stated staff will enter the pass code and will escort residents to the outside area. LPA observed a keypad which leads back inside to the memory care section. LPA observed a fenced in area. There is a keypad located at the east side of the fenced in area which leads out of the memory care section. There is a second gate on the west side that allows another exit from the memory care outside area. LPA observed a keypad at the gate..

Common areas - LPA observed a dining area which contained dining room tables and chairs. There is also a sitting area for residents and visitors to enjoy. The sitting area contained comfortable seating.

Bedroom Suites – There are eight single resident suites which contained a bedroom/bathroom combination. The suit was spacious and contained a bed, mattress and comfortable seating, closet and adequate lighting. The bathroom contained grab bars, and slip resistant strips in the walk-in shower.

Companion Suites- There are five companion suites. When entering the suite, LPA observed a sitting area with a table and two chairs. The bathroom is shared by two residents and contained grab bars and slip resistant strips in the walk-in shower. The two bedrooms contained a bed, mattress, closet and adequate lighting.

Upon concluding the tour, LPA did not observe any health or safety issues

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

LIC809 (FAS) - (06/04)

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