197609720-4-14-2022-31-AS-CHAS-CDXVSF-20220429164126

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609720
Report Date: 04/14/2022
Date Signed: 04/14/2022 05:14:08 PM

Unsubstantiated

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
03/16/2021 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20210316081307

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: 84	DATE:	04/14/2022
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Mindy Mendoza-Perry		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Facility staff threatened resident with eviction.
Resident experienced unexplained weight loss.
Staff did not allow resident to leave his room.
Staff searched through resident’s personal belongings.

INVESTIGATION FINDINGS:

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Licensing Program Analyst Melissa Spaeth conducted an unannounced visit regarding a complaint which states facility staff threatened resident with eviction, resident experienced unexplained weight loss, staff did not allow resident to leave his room, and staff searched through resident's personal belongings.

LPA was greeted by the Administrator and LPA stated the purpose of the visit. LPA interviewed staff members from 11:30 am until 1:30 pm. and interviewed eight residents from 3:30 pm until 4:00 pm. Based upon LPA's interviews of staff members, complainant, residents, and review of resident's records, LPA has completed the investiation with the following findings.

Facility staff threatened resident with eviction - LPA interviewed the Business Office Manager (S4) who stated did not verbally threaten R1 with an eviction notice but tried to assist R1 with reviewing monthly facility billing statements. S4 also stated R1 experienced issues with banking transactions and was having a difficult time paying own bill. But staff provided R1 transportation to the bank when needed. The Community Sales

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: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

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

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20210316081307

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: 04/14/2022

NARRATIVE

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Director (S3) confirmed S4's comments. S3 stated would transport R1 to the bank whenever was asked to assist. S3 also stated never verbally threatened R1 with an eviction notice. Based upon the facility's payment policy, a termination of assisted living care letter dated January 27, 2021 was given to R1 which was a 30 day notice. However, the termination was not implemented and the resident was allowed to stay and moved out of the facility December 18, 2021. Therefore, this allegation is unsubstantiated

Resident experienced unexplained weight loss – LPA Spaeth interviewed three staff members who were working at the time R1 was a resident. All three staff members confirmed did not witness R1 loosing an extreme amount of weight. Two of the three staff members stated had witnessed R1 eating a healthy amount of food. The three staff members also stated there is an adequate supply of food for the residents and have never witnessed a resident stating was hungry and did not have enough food to eat. LPA interviewed eight residents who stated receive enough food and that there is an abundance of food for the residents at each meal. Therefore this allegation is unsubstantiated.

Staff did not allow resident to leave his room – LPA spoke to complainant who stated during the month of January, 2021 and February 2021, Residents were not allowed to leave room. LPA stated to the complainant there were confirmed COVID cases and the Los Angeles Department of Health had stated the facility residents should be quarantined during that period of time.

LPA spoke to staff who stated there were positive COVID-19 residents in the the facility during those months so residents were quarantined in rooms but residents were able to talk to family members on the phone. LPA confirmed the facility had reported the COVID cases during those months. LPA interviewed staff members who confirmed meals were delivered to the residents in residents' rooms. Therefore, this allegation is unsubstantiated.

Staff searched through resident’s personal belongings – LPA interviewed three staff members who confirmed R1 had requested staff members find missing items in R1's room. All three confirmed that at least two staff would search the room and that R1 was always present when search began. Therefore, this allegation is unsubstantiated.

Exit interview conducted, appeal rights discussed, and a copy of the report was given to the Administrator.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC9099 (FAS) - (06/04)

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