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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609720
Report Date: 02/14/2022
Date Signed: 02/14/2022 04:34:00 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
02/07/2022 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20220207102242
FACILITY NAME:HAVENS AT ANTELOPE VALLEY ASSISTED LIVING, THEFACILITY NUMBER:
197609720
ADMINISTRATOR:AUTUMN ROBERTS RODRIGUEZFACILITY TYPE:
740
ADDRESS:43051 15TH SREET WESTTELEPHONE:
(661) 723-8525
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:115CENSUS: 77DATE:
02/14/2022
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Autumn Roberts RodriguezTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff did not provide proper medication assistance to resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst(s) Melissa Spaeth and Wendell Smith conducted an unannounced subsequent complaint visit to finish investigation into the allegation above. LPA's met with the administrator and explained the reason for this visit.
LPA's conducted a brief physical plant tour from 9:50-10:05am to ensure no immediate health and safety issues were noted. Regarding the allegation LPA Spaeth conducted the initial visit on 2/9/22 where interviews were conducted with facility staff and residents. During today's visits interviews were conducted with residents from 10:05-11:15am. LPA's also obtained and reviewed documentation related to the complaint allegation from 11:15-11:45am. Information from interviews reveal that on 2/4/22, 2/5/22, and 2/6/22 five residents completely missed all of their medications and twenty-six residents received their medication late. Administrator admitted that this occurred and stated they had some staff unexpectedly call out which created an issue for the facility. The facility called Pegasus doctor to determine how to proceed with giving medications based on how much time had elapsed between medications being missed or being given later than usual.
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: 02/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2022
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 3
Control Number 31-AS-20220207102242
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: 02/14/2022
NARRATIVE
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LPA Spaeth reviewed resident files from 3:45 pm until 4:00 pm. LPA requested copies of residents' documentation.

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.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 31-AS-20220207102242
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: 02/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/14/2022
Section Cited
CCR
87465(c)(2)
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Incidental Medical and Dental Care-Once ordered by the physician the medication is given according to the physician's directions.
This requirement was not met as evidenced by:
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Corrected before visit. Administrator hired a new health & wellness director and two new med techs to over see medications. LPA was able to verify that the new hires have the appropriate training for the position.
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Based on interviews conducted it was found that five residents were not given their medications at all and twenty six residents were given their medication late which posed an immediate health and safety risk to the residents in care.
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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: 02/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3