197609720-12-17-2025-31-AS-TAGD-DPUPDG-20251230101332

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609720
Report Date: 12/17/2025
Date Signed: 12/17/2025 02:04:16 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
12/12/2025 and conducted by Evaluator Angelica Segovia

COMPLAINT CONTROL NUMBER: 31-AS-20251212205153

FACILITY NAME:	HAVENS AT ANTELOPE VALLEY ASSISTED LIVING, THE		FACILITY NUMBER:	197609720
ADMINISTRATOR:	KATHERINE ALEMAN		FACILITY TYPE:	740
ADDRESS:	43051 15TH SREET WEST		TELEPHONE:	(661) 723-8525
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY:	115	CENSUS: 102	DATE:	12/17/2025
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Jeff Gollihar- Executive Director		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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Staff did not reappraise resident for a change in condition

INVESTIGATION FINDINGS:

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On 12/17/2025 at approximately, 10:00 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced initial complaint visit to the facility to investigate the above allegation(s). LPA was greeted by staff and stated the reason for their visit. LPA was informed that the Executive Director, Katherin Aleman no longer works at the facility. LPA was greeted by the temporary Executive Director, Jeff Gollihar who assisted with today's visit.

At 10:05 AM, LPA requested census, resident, and staff roster. At approximately 10:20 AM, LPA conducted a physical plant tour, to ensure the health and safety of the residents. At 11:00 AM, LPA requested pertinent documentation pertaining to the investigation such as but not limited to: Pre-placement Appraisal, Needs and Services and Physician’s Report. In between 11:30 AM – 1:30 PM, LPA conducted interviews with two (2) staff members (S1-S2) and conducted record review.

(Continue to LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 31-AS-20251212205153

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: 12/17/2025

NARRATIVE

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Regarding the allegation: Staff did not reappraise resident for a change in condition. It was alleged that staff failed to conduct a proper reassessment for Resident 1 (R1). To investigate the allegation, LPA conducted interviews with two (2) staff members. LPA’s interview with S2 revealed that residents are reappraised every six (6) months, or first 30 days upon their move-in date or if there is a change of condition noted. During LPA’s record review, LPA observed R1’s latest re-appraisal (listed as Functional Evaluation for this investigation) to have been done on 6/16/2025. R1’s Admission date was documented as 6/06/2025. When questioned as to why R1’s re-appraisal documented them to have “Short term/memory impairment” with “…occasional confusion and some difficulty in recalling, “details”, S2 stated that although R1 has not been diagnosed with any cognitive impairments, they have been observed to have some forgetfulness. LPA’s review of R1’s Pre-placement Appraisal dated 5/30/2025 confirmed R1’s mental condition was documented as Mild Cognitive Impairment (MCI) which collaborated with their current Functional Evaluation. LPA’s review of R1’s Physician Report dated 5/30/2025, R1’s diagnosis were documented as various medical conditions but no indication of MCI’s notated nor discussed. R1’s Physician's Report documented them as followed but not limited to:

Lack of Hazard Awareness- No

Lack of Impulse Control- No

Unsafe Wandering- No

Sundowning Behavior- No

Elopement- No

Additional, record review of R1’s Unusual Incident Reports (SIRs) dated 11/26/2025 and 12/9/2025 documented R1 to have had unwitnessed falls near their bedside where they sustained injuries requiring them to be sent to the hospital. LPA’s record review of R1’s current Functional Evaluation report documented R1’s fall Risk to have, “non slip shoes when transferring/ambulating…”. However, due to R1’s falls, S2 stated that they ordered a fall mat to be placed by R1’s bedside and a high-back wheelchair. LPA confirmed the orders dates of 12/11/2025 and 12/15/2025 of said items. During LPA’s physical plant tour, LPA observed R1’s bedroom to be neat, clean and organized. LPA observed R1’s fall mat next to their bed and their high-back wheelchair. LPA observed R1 to be asleep. LPA observed no obstructions or tripping hazards in R1’s bedroom. (Continue to LIC 9099-C)

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20251212205153

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: 12/17/2025

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Based on interviews, record review and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview conducted and a copy of this report was provided to the temporary Executive Director.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025

LIC9099 (FAS) - (06/04)

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