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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609720
Report Date: 12/23/2024
Date Signed: 12/23/2024 02:45:58 PM

Document Has Been Signed on 12/23/2024 02:45 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:HAVENS AT ANTELOPE VALLEY ASSISTED LIVING, THEFACILITY NUMBER:
197609720
ADMINISTRATOR/
DIRECTOR:		KATHERINE ALEMANFACILITY TYPE:
740
ADDRESS:43051 15TH SREET WESTTELEPHONE:
(661) 723-8525
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 115TOTAL ENROLLED CHILDREN: 0CENSUS: 91DATE:
12/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Marhlyn Sapugay- Director of EngagementTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 12/23/2024 at approximately 09:45 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced annual visit to the facility. Upon arrival LPA was greeted by the Director of Engagement Marhlyn Sapugay. LPA stated the reason for their visit. The Administrator was phoned shortly after and made aware of today’s visit.

LPA asked for census, staff, and resident file. LPA along with Director Sapugay conducted a physical plant tour at approximately 12:30 PM and the following was noted:

The facility is a two-story building. The facility is fire cleared for one hundred fifteen (115) non-ambulatory residents and a Hospice waiver for six (6). The facility consists of Assisted Living located on both floors and Memory Care located on the first floor. Smoke detectors and carbon monoxide observed to be working properly and in good repair. Smoke alarms were last inspected on 10/31/24. There are fire extinguishers located throughout the facility hallways. Fire extinguishers dated 05/02/24.

Required postings such as Emergency Disaster Plan, Facility License, and Facility sketch are located at the main entrance. Screening area is located immediately upon entrance.

Common areas: observed to be neat, clean, and organized. Common areas observed to be properly furnished and in good repair. Such included are: Dining room, Activity room, Theater/Chapel, Mail room, Beauty Parlor and Fitness center (located on the second floor). Hallways and passageways are free of obstruction. Stairway observed to be equipped with an evacuation chair. Elevators, two (2), were functional. The facility maintains a comfortable temperature at a range of 71°F - 74°F throughout the facility. Fireplace observed to be covered inaccessible to residents.

Office/Work Station: The Administrator's office and sales and marketing room are located near the main entrance, near the front desk. (continued on LIC 809-C)

Troy AgardTELEPHONE: (818) 596-4342
Angelica SegoviaTELEPHONE: (818) 669-6375
DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2024
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
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: 12/23/2024
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The kitchen is commercial. Appliances and fixtures were functional. The kitchen observed to be fully stocked with two (2) days perishable and seven (7) days non-perishable food. Kitchen observed to be clean and inaccessible to pests.

Surrounding Grounds: The Memory Care is located on the first floor with thirteen (13) rooms and a capacity of eighteen (18) residents. LPA observed both dining room and living room to be in good repair and free of obstructions. LPA observed delayed egress to be in good repair and working condition. Outside of the memory care, there is an enclosed courtyard with open space Gazebo.

Outside area of the Assisted Living is equipped with a gazebo and sufficient shaded areas with outdoor furniture for residents. There is no body of water in this facility.

Laundry Room: There are three (3) laundry rooms. One commercial laundry room is located on the first floor, besides the medication room. There are two (2) community laundry rooms located on the second floor for residents to use. The commercial laundry room is kept locked. The community laundry rooms have resident access, but no detergents or cleaning supplies accessible. Residents who wish to do their laundry, are to bring their own.

The Residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lighted appropriately. The bathrooms were checked for cleanliness and proper operation. LPA observed proper handrails and non-skid mats. The hot water temperature was measured at a range of 113.5°F-120°F. Towels and washcloths are not shared.

Medications: LPA observed medication room located on the first floor. Medication room is kept locked and inaccessible to residents. Medication usage recorded and stored properly. LPA along with Director Sapugay conducted a review of the medication to ensure compliance. First-aid kit observed to be equipped with but not limited to bandages, scissors, digital thermometer, tweezer, and manual.

Resident records: LPA conducted a file review of resident records. Resident records appeared to be complete and updated. Staff records: LPA conducted a file review of staff records. Staff records appeared to be complete and updated.

There was no immediate health and safety hazard observed during the day of inspection. Exit interview conducted and a copy of this report was provided to the Director.

SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Angelica SegoviaTELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC809 (FAS) - (06/04)
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