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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609720
Report Date: 02/28/2022
Date Signed: 02/28/2022 02:46:16 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, THEFACILITY NUMBER:
197609720
ADMINISTRATOR:BROCK, FREDAFACILITY TYPE:
740
ADDRESS:43051 15TH SREET WESTTELEPHONE:
(661) 723-8525
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:115CENSUS: 80DATE:
02/28/2022
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Andrea GutierrezTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Facility is understaffed.
INVESTIGATION FINDINGS:
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LPA Spaeth conducted an unannounced subsequent complaint visit to finish investigation into the allegation above. LPA met with the Andrea Gutierrez and explained the reason for this visit.

LPA's conducted a brief physical plant tour to ensure no immediate health and safety issues were noted. Regarding the allegation LPA Spaeth conducted resident interviews on 7/15/2020 and 12/01/2021 where interviews were conducted with facility staff and residents. Information from interviews reveal that ten out of the sixteen residents interviewed stated had to wait over thirty minutes for staff to respond to resident's request for assistance. Three residents stated when staff member did respond after a thirty minute wait, staff commented to residents that facility was short handed.

Based on the information obtained through interviews this allegation is deemed Substantiated. Deficiency cited on LIC 9099 D. Appeal rights were discussed, exit interview conducted, and a copy of the report was given to the Administrator.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2022
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 2
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: 02/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2022
Section Cited
CCR
87411(a)
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87411 Personnel Requirements-General (a) facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.... This requirement was not met based upon:
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Staff Gutierrez has confirmed have one med tech and two caregivers during the day along with an additional part time caregiver to provide showers for those residents when needed. For the night shift, there are two caregivers. One caregiver is also a med tech who can provide medications for any residents during the night
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Facility does not have sufficient staff which resulted in residents waiting long times to receive care from staff in a reasonable time.
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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 HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2022
LIC9099 (FAS) - (06/04)
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