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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609720
Report Date: 03/08/2022
Date Signed: 03/08/2022 04:57:49 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
03/07/2022 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20220307085159
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: 75DATE:
03/08/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Andrea GutierrezTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff stole from resident.
Resident not accorded dignity in relationships with staff.
Facility air conditioning unit not working.
Staff did not meet resident's incontinence needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced complaint visit to investigate the allegations above. LPA met with facility staff and explained the reason for this visit.

Staff stole from resident and Resident not accorded dignity in relationships with staff
It is alleged that staff #1 (S1) stole food from resident #1 (R1) which has caused R1 to worry whenever staff enters their room and staff have yelled at R1 in the past during their time in the facility. LPA conducted an interview with facility staff regarding this allegation from 10:15am-10:45am. LPA also reviewed R1 and S1's facility file from 10:45am-12pm. Information from interviews revealed that S1 would enter R1's room and go into R1's refrigerator and take things without R1 knowing. R1 is non-ambulatory and cannot get up without assistance. When R1 is in their room they are not able to see someone enter their room and does not have visual of the kitchen. LPA was able to view several videos on 1/30/22 of S1 going into R1's room and taking food items out of R1's refrigerator. Interviews with facility staff indicate that S1 did take food from R1's room and that R1 was suspended from work based on their own internal investigation.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
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 4
Control Number 31-AS-20220307085159
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: 03/08/2022
NARRATIVE
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LPA interviewed R1 regarding this allegation from 12:30pm-1pm. It was also brought to LPA's attention that back in 2020 when R1 moved in there was an incident where S2 yelled at R1. An investigation was conducted and that specific staff was terminated from their job. Based on the information obtained through interviews and video observation both of these allegations are deemed Substantiated at this time.

Facility air conditioning unit not working.
It is alleged that R1 had to change rooms back when they first moved in due to their air conditioning unit in their room not working properly. LPA conducted interviews with R1 and facility staff regarding this allegation. Interviews revealed that when R1 moved in, in September 20,2020 they were moved into room #243 and had to change rooms to the first floor due to an issue with the air conditioning unit in their room. Based on the information obtained through interviews this allegation is deemed Substantiated.

Staff did not meet resident's incontinence needs.
It is alleged that when R1 pushes their pendant for assistance it can take a long time for staff to respond. LPA interviewed R1 and facility staff regarding this allegation. Facility staff stated that their policy when residents push their pendant is to respond within seven minutes. Administrator was able to pull a report that shows the response time to when staff responded to R1's pendant being pushed. LPA was able to obtain the response time for February 2022 through today's date. A review of this document shows that there were several instances where R1 waited over fifteen minutes up to an hour to get assistance. Based on the information obtained this allegation is deemed Substantiated.
All deficiencies cited on LIC 9099 D. Appeal Rights explained. Exit Interview conducted.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20220307085159
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: 03/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/08/2022
Section Cited
CCR
87468.1(a)(1)
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Personal Rights of Residents in All Facilities-To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement was not met as evidenced by:
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Corrected before visit. Facility has suspended S1 and S2 was terminated from their job.
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Based on interviews conducted it was found that S1 stole food from R1 and other staff have yelled at R1. This poses an immediate health and safety risk to residents in care.
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Type A
03/10/2022
Section Cited
CCR
87468.(a)(3)
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Personal Rights of Residents in All Facilities-To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.
This requirement was not met as evidenced by:
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Corrected before visit. S1 was suspended and is not allowed to work with R1.
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Based on interviews conducted it was found that staff's actions towards R1 has caused interference with R1's eating and sleeping patterns which posed an immediate health and safety issue to 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: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20220307085159
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: 03/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/09/2022
Section Cited
CCR
87468.1(a)(2)
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2
3
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7
Personal Rights of Residents in All Facilities-To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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Administrator will have an in-service with staff on response times to all resident's pendants and emphasize that staff is to respond within seven minutes. Copy of in-service will be sent to LPA.
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Based on interviews conducted it was found that after pressing their pendant R1 has had to wait more than 15 minutes on several occassions which poses an immediate health and safety risk to residents in care.
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Type B
03/08/2022
Section Cited
CCR
87303(a)
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Maintenance and Operation- The facility shall be clean, safe, sanitary and in good repair at all times.
This requirement was not met as evidenced by:
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Corrected before visit. R1 was moved rooms.
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Based on interviews conducted R1 air conditioner was not working properly. This posed a potential health and safety risk to R1.
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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: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4