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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609720
Report Date: 05/20/2025
Date Signed: 05/20/2025 12:55:38 PM

Document Has Been Signed on 05/20/2025 12:55 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: 98DATE:
05/20/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:KATHERINE ALEMAN- Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
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On 5/20/2025 at approximately 10:30 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced subsequent Case Management visit to the facility. LPA was greeted by staff and stated the reason for their visit was to deliver the findings regarding the incident reported to Community Care Licensing Division (CCLD) on 5/2/2025. Executive Director (ED) Katherine Aleman arrived shortly after to assist with today’s visit.

Upon arrival, LPA requested Census, Staff and Resident Roster. At approximately 10:40 AM LPA requested additional documentation pertaining to the incident. Between 11:00 AM – 12:00 PM, LPA conducted additional interviews with Staff members (S5-S6).

To investigate the incident, on 5/5/2025 LPA conducted a physical plant tour, requested pertinent documentation, and conducted interviews with one (1) Resident (R1) and four (4) Staff members (S1-S4).

The facility reported that R1 had reported that S1 used inappropriate physical force towards them causing them pain. LPA spoke with the ED regarding the incident between R1 and S1. The ED stated that when they became aware of the alleged incident, they proceeded to conduct their own internal investigation as well as reporting the incident to the appropriate domains. The ED stated they interviewed both R1 and S1 but since there were no witnesses their investigation was inconclusive. LPA’s interview with R1 revealed that S1 had arrived in their room in the morning to assist them in bed with their incontinent care needs. R1 stated that S1 pushed their head down twice by placing their finger onto their forehead to get their head onto the bed. When LPA asked if they could name the staff member, R1 could not remember and stated, “I am not good with names”.When LPA asked if they had told anyone what had occurred, R1 stated they told S3 what had occurred. LPA’s interview with S3 revealed that R1 had told them that a staff member had “manhandled” them when assisting them in the morning. When LPA asked if R1 had told them the name of the staff member, S3 stated that R1 did not know the name of the staff member. (Continue to LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Angelica Segovia
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 05/20/2025
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LPA’s interview with S1 revealed that they went to R1’s room in the morning to assist them with changing in bed. S1 stated that R1 has had surgery to their neck causing them to keep their neck in an upward position. S1 stated that when they changed S1, they placed a pillow behind their neck to help with their positioning. When LPA asked if they ever used their fingers to push R1’s head back towards the bed, S1 stated, “No, that is why I use the pillow to help position them”. While interviewing R1, LPA observed R1 keeping their neck in an upward position creating distance from their pillow to their neck.

LPA’s Interview with S6 revealed that R1 did name S1 as the person involved in the incident however, interviews with S2-S6 revealed although R1 stated that said incident occurred, there were no witnesses.

Furthermore, based on interviews, record review and observation there is not enough evidence to prove that S1 physically hurt R1. No deficiencies cited at this time.

No immediate health and safety hazards observed during the visit. Exit interview conducted and a copy of this report was provided to the Executive Director.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Angelica Segovia
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
LIC809 (FAS) - (06/04)
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