197609720-2-9-2022-31-AS-MSPH-CBGSVA-20220209131226

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609720
Report Date: 02/09/2022
Date Signed: 02/09/2022 01:13:51 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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

FACILITY NAME:	HAVENS AT ANTELOPE VALLEY ASSISTED LIVING, THE		FACILITY NUMBER:	197609720
ADMINISTRATOR:	AUTUMN ROBERTS RODRIGUEZ		FACILITY TYPE:	740
ADDRESS:	43051 15TH SREET WEST		TELEPHONE:	(661) 723-8525
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY:	115	CENSUS: 77	DATE:	02/09/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Autumn Rodriguez		TIME COMPLETED:	12:30 PM

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	LPA Spaeth conducted an unannounced visit and was greeted by Administrator, Autumn Rodriguez at 10:00 am. Upon approaching the front door LPA observed the COVID signs on the entrance doorway. LPA's temperature was taken, COVID questions answered, and LPA observed hand sanitizer available at the front reception desk. LPA Spaeth was escorted by staff member, Gustavo Regin at 10:10 am. for a tour of the facility. LPA observed a large sitting area at the front entrance with comfortable seating for residents and guests. LPA observed three residents sitting within this area and were wearing masks. Within the activity section of the front entrance, LPA observed three residents and a staff member who were exercising. All four individuals were wearing masks. LPA observed four resident apartments on the first floor. The apartments were set up with a small kitchen, living area, bedroom, and a bathroom. The bathrooms all contained grab bars, slip resistant mats, hand soap, and trash cans. The beds were furnished with linens and the apartments contained adequate lighting. LPA then viewed four apartments on the second floor and observed the apartments all contained the regulation requirements. Upon returning to the first floor, LPA observed the dining room which was prepared for the noon meal. All tables were set with fresh linens. There were three kitchen staff who were wearing masks and gloves. The kitchen staff were preparing food for the noon meal. LPA was introduced to David Hernandez, Dining Hall Director, who was wearing a mask and stated the residents will be served herb roasted turkey, potato salad, asparagus and blueberry pie.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HAVENS AT ANTELOPE VALLEY ASSISTED LIVING, THE	FACILITY NUMBER: 197609720
	VISIT DATE: 02/09/2022

NARRATIVE

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At 10:40 am, LPA observed the walk in refrigerator contained prepared lunch items which were properly wrapped, dairy products, fresh fruits, and vegetables. LPA observed an adequate supply of frozen meats and vegetables in the freezer. The pantry was well stocked with a seven day supply of canned fruits, vegetables, and pasta. LPA observed the canned goods were labeled with expiration dates and there were no expired canned goods in the pantry.

LPA observed the employee break room and bathroom. There was adequate ventilation in the break room and the bathroom contained wash your hands sign, hand soap, paper towels, and a trash can. The two public bathrooms also contained wash your hands sign, hand soap, paper towels, and a trash can. The resident laundry room which is used by residents contained washer/dryers and a trash can. The laundry room used by staff for washing residents' clothing also contained a trash can. LPA observed the facility was clean.

At 12:37 pm, LPA and Administrator met to discuss LPA's findings. LPA requested a copy of the staff's vaccine dates and Administrator did provide an excel spreadsheet which contained all the vaccine information.

There are no deficiencies to report at this time. Exit interview conducted, appeal rights discussed, and a copy of the signed report will be emailed to the Administrator.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022

LIC809 (FAS) - (06/04)

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