<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609720
Report Date: 05/28/2026
Date Signed: 05/28/2026 01:25:27 PM

Substantiated


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
05/21/2026 and conducted by Evaluator Angelica Segovia
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20260521164911
FACILITY NAME:HAVENS AT ANTELOPE VALLEY ASSISTED LIVING, THEFACILITY NUMBER:
197609720
ADMINISTRATOR:PENDA E HODGESFACILITY TYPE:
740
ADDRESS:43051 15TH SREET WESTTELEPHONE:
(661) 723-8525
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:115CENSUS: 83DATE:
05/28/2026
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Penda Hodges- AdministratorTIME COMPLETED:
01:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not call emergency services for resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 5/28/2026 at approximately 9:40 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced initial complaint visit to the facility. LPA was greeted by the Administrator, Penda Hodges and stated the reason for their visit.


To investigate the allegation(s), at approximately 10:00 AM, LPA requested relevant documentation such as but not limited to: Staff schedule, Staff Timecard Report, Hospital discharge paperwork. By 11:00 AM, LPA conducted a physical plant tour. From 10:00 AM to 1:00 PM, LPA conducted interviews with one (1) resident (R1), two (2) staff members (S1-S2) and conducted record review.


(continue to LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
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-20260521164911
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: 05/28/2026
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
Regarding the allegation: Staff did not call emergency services for resident. It was alleged that S2 did not call emergency services for R1. Per the Reporting Party (RP), when they spoke with S2, S2 revealed they did not call emergency services for R1 due to them being on break and they have been directed to follow this per the facility’s policy. To investigate the allegation, LPA conducted interviews with one (1) resident and two (2) staff members. LPA’s interview with R1 revealed the night of said incident they alerted staff to their room due to severe abdominal pain but were informed by S2 that they would not assist them with calling emergency services due to them being on break. R1 stated that, as a result, they needed to contact emergency services themselves. LPA’s interview with S1 revealed S2 informed them of what had occurred with R1 where it was revealed S2 proceeded to clock back in from break prior to calling emergency services for R1. When questioned if it is the facility’s policy for staff not to call emergency services for residents when on break/lunch, S1 stated, “No”. LPA’s interview with S2 confirmed R1’s interview. Per S2, they stated they told R1, “…once I clock back in, I will call 911”.

Based on interviews, S2 confirmed they did not contact emergency services for R1, resulting in R1 having to contact emergency services themselves. Therefore, the allegation is SUBSTANTIATED at this time.

No other immediate health and safety issues observed during the day of the visit. Exit interview was conducted, appeal rights given, and a copy of this report was provided to the Administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20260521164911
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/11/2026
Section Cited
CCR
87415(a)(2)
1
2
3
4
5
6
7
87415 Night Supervision.(a) The following persons providing night supervision...shall be available...to assist in caring for residents in the event of an emergency...(2)employee shall be on call, and capable of responding.

This requirement was not met evdienced by:
1
2
3
4
5
6
7
The Licensee/Administrator will conduct in-service training with staff including S2 and email LPA Segovia the staff training regarding policy/procedure regarding emergency services by POC due date.

POC due date: 6/11/2026
8
9
10
11
12
13
14
Based on interviews, S2 confirmed they did not call emergency services for R1 which poses a potential Health, Safety, or Personal Rights risk to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3