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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609720
Report Date: 01/21/2025
Date Signed: 01/21/2025 03:04:38 PM

Document Has Been Signed on 01/21/2025 03:04 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: 115CENSUS: 97DATE:
01/21/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Katherine Aleman- Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 1/21/25 at 10:00 AM, Licensing Program Analysts (LPAs) Angelica Segovia and Gary Tan conducted an unannounced visit to the facility to conduct a Case Management visit. LPAs were greeted by Executive Director Katherine Aleman. LPAs stated the reason for their visit. The purpose for the visit was to follow up on a self-reported incident (1-13-25) which alleged that Resident 1 (R1) was involved in a physical and verbal altercation with Staff 1 (S1) on 1-10-25.

LPAs requested census, staff, and resident Rosters at 10:15 AM. LPAs reviewed pertinent documents from 10:20 AM-12:30 PM. A physical plant tour was conducted at 12:35 PM. LPAs interviewed staff members and Resident 1 (R1) from 12:50 PM to 2:30 PM. Interview with R1 revealed that they had called down for their medication request around 3:30 PM. R1 stated they waited, and no one came to their room until 6:30 PM. R1 stated they were upset because they wanted their medication for pain. R1 stated they suffer from frequent migraines. LPAs record review revealed that R1 had a PRN medication for pain every six (6) hours and the last PRN pain medication administered to R1 was at 12:00 PM and the next one is not due until 6:00 PM as this is a narcotic pain medication. During the medication pass conducted to R1 at own room by Staff #1 (S1) at around 6:30 PM, R1 stated that there was a physical altercation with S1 as R1 argued that S1 was late in giving R1’s medication. An altercation ensued when R1 initially refused medication and S1 allegedly tried to grab R1’s medication on R1’s hand resulting to scratches on R1’s hands. LPAs record review and interview with the Executive Director (ED) revealed that ED talked to R1 by phone at around 8:28 PM and R1 told ED that R1 was okay when R1 mentioned he had a cut on their hand. At 9:31 PM, however, the ED received a picture from R1 showing a fresh scratch on R1’s hands. Record review showcased that R1 has a history of false reporting, self-inflicting wound, and aggressive behavior. During the interview with S1, S1 denied having any physical contact with R1.

Based on LPAs’ record review and interviews, there is not enough information to prove that S1 physically hurt R1. No further actions needed at this time and no immediate health and safety issues observed during this visit. Exit interview conducted. A copy of this report was given to the Executive Director.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
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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