197609720-8-19-2021-31-AS-CHAS-CC6UTP-20220303145213

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609720
Report Date: 08/19/2021
Date Signed: 08/19/2021 05:21:23 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/13/2020 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20200713165406

FACILITY NAME:	HAVENS AT ANTELOPE VALLEY ASSISTED LIVING, THE		FACILITY NUMBER:	197609720
ADMINISTRATOR:	BROCK, FREDA		FACILITY TYPE:	740
ADDRESS:	43051 15TH SREET WEST		TELEPHONE:	(661) 723-8525
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY:	115	CENSUS: 77	DATE:	08/19/2021
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:			TIME COMPLETED:	04:55 PM

ALLEGATION(S):

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Staff caused injury to residents in care.
Staff handle residents in a rough manner
Unqualified staff are providing hospice services to residents in care.
Staff are hiding residents call buttons.
Resident's therapy needs are not being met.
Facility staff is understaffed.

INVESTIGATION FINDINGS:

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LPA Spaeth conducted an unnanounced visit regarding the above-referenced allegations and arrived at 2:20 pm. LPA Spaeth met with Christine Ellis and explained the purpose of the visit is to complete the complaint investigation.

LPA Spaeth reviewed resident physical therapy records from 3:00 pm until 3:20. LPA observed there are three residents receiving physicial therapy and records indicate the residents have not missed physical therapy appoinments. Therefore the allegation stating resident's therapy needs are not being met is unsubstantiated. In regard to the allegations which states staff caused injury to residents in care and staff handled residents in a rough manner. LPA interviewed seven residents and all residents stated the allegations that staff caused injury to resident in care and staff handled residents in a rough manner did not occur. Therefore the two allegations are unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

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 4

Control Number 31-AS-20200713165406

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/19/2021

NARRATIVE

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LPA Spaeth interviewed five staff members asking if caregivers had provided hospice services to residents in care. All five staff members stated no and stated only the Hospice agency nurses provide Hospice services to the residents. Therefore the allegation that states unqualified staff are providing hospice services to residents in care is unsubstantiated.

Complainant had stated staff members had not received proper CPR training. LPA Spaeth observed the CPR training records from 4:00 pm until 4:10 pm. However, LPA observed all staff members have received the proper CPR training. Therefore the allegation is unsubstantiated.

In regard to the allegation that staff member are hiding the resident's call buttons. LPA spoke to five staff members and seven residents who all stated the call buttons have not been hidden by staff. Therefore this allegation is unsubstantiated.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/13/2020 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20200713165406

FACILITY NAME:	HAVENS AT ANTELOPE VALLEY ASSISTED LIVING, THE		FACILITY NUMBER:	197609720
ADMINISTRATOR:	BROCK, FREDA		FACILITY TYPE:	740
ADDRESS:	43051 15TH SREET WEST		TELEPHONE:	(661) 723-8525
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY:	115	CENSUS: 77	DATE:	08/19/2021
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Christine Ellis		TIME COMPLETED:	04:55 PM

ALLEGATION(S):

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Staff are not meeting resident's hygiene needs.

INVESTIGATION FINDINGS:

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LPA Spaeth interviewed five residents who receive incontinent care. Three residents stated had to wait over thirty minutes for assistance from the staff. LPA Spaeth also interviewed a family member who was visiting a resident who stated the resident had to wait over thirty minutes for assistance. During the resident interviews, three residents stated were physically uncomfortable waiting for assistance.

Pursuant to Title 22 California Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Exit interview conducted and a copy of the report along with the appeal rights provided to lidcensee via email.

Exit interview conducted, appeal rights discussed and LPA confirmed a copy of the report will be emailed to the manager.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 31-AS-20200713165406

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/19/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/31/2021 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rigths of All Residents in All Facilities (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights. (a) To be accorded safe, healthful & comfortable accommodations...	1 2 3 4 5 6 7	Erica Reyes, Health and Welless Director, has begun the process addressing the call light time issue and began inservice training for all caregivers. A resident had brought this to Health & Wellness Director.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews of residents and family members, the staff failed to assist in a timely manner with resident's incontinent needs.	8 9 10 11 12 13 14	Health & Wellness Director has a computer printout with the amount of time each request took. Caregivers were instructed as of today to identify the cause of delay of respond times. Health R Wellness Director will evaluate the response time and will report to LPA the findings.
	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.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4