197609720-7-11-2024-31-AS-NGID-D7MURR-20240729154906

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609720
Report Date: 07/11/2024
Date Signed: 07/11/2024 03:13:38 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.RO, 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
07/03/2024 and conducted by Evaluator Huma Rahimi

COMPLAINT CONTROL NUMBER: 31-AS-20240703123202

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: 95	DATE:	07/11/2024
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Amber Fraser, Wellness Specialist		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Licensee is not following proper infection control protocols.

INVESTIGATION FINDINGS:

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At 10:10am, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPA met with the receiptionist and later met with Wellness Specialist and explained the reason for the visit.

During course of the investigation, interviews and record review were made. At 10:20am, LPA requested resident and staff roster and copies of pertinent information which include, but not limited to an Approved Infection Control Plan, Hospital Discharge Papers, Notes, Physician’s Report, Appraisal Needs and Services Plan, etc., relevant to the investigation. At approximately 10:35am, LPA conducted a physical plant tour. Between 10:45 am – 1:20 pm, LPA conducted an interviewed with the Wellness Specialist, Memory Care Director, Executive Director, two (2) staff, and nine (9) out of eleven (11) residents.

Continue on LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

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-20240703123202

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: HAVENS AT ANTELOPE VALLEY ASSISTED LIVING, THE	FACILITY NUMBER: 197609720
	VISIT DATE: 07/11/2024

NARRATIVE

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Licensee is not following proper infection control protocols:
It was alleged that the facility is exposed to Scabies and was not disclosed to family members. To investigate this allegation, LPA conducted interviews with the Wellness Specialist, Executive Director, and Memory Care Director and it was revealed that in March 2024 one of the residents (R1) was having a skin rash. Upon observation, the facility informed the family member of R1. The family member took R1 to the physician on 03/14/2024, 04/03/2024, and 05/28/2024, for the skin rash. Finally, on 06/20/2024, R1 was taken to Kaiser Permanente Dermatologist for the ongoing skin rash by a family member and R1 was diagnosed for Scabies without any confirmed tests. Upon diagnosis of the doctor, the facility followed proper infection control protocols by quarantining R1 in their room for five (5) days and immediately all the beddings were changed. Interview with the family member of R1 confirmed that the facility did inform them in a timely manner and as well isolated R1 immediately and washed all their beddings and clothes. Additionally, the facility also followed proper reporting procedures by reporting to the Community Care Licensing Department (CCLD). Lastly, interview with nine (9) out of eleven (11) residents also confirmed that the facility always follows proper infection control plan and they have no concerns regarding the above allegation. Based on the interviews and record review this allegation is deemed Unsubstantiated at this time.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

LIC9099 (FAS) - (06/04)

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