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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608302
Report Date: 03/22/2024
Date Signed: 03/22/2024 11:11:17 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
03/20/2024 and conducted by Evaluator Evelin Rios
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20240320161058
FACILITY NAME:LANCASTER HAVEN RCFEFACILITY NUMBER:
197608302
ADMINISTRATOR:MARIA MAXIMA BASCOS, RNFACILITY TYPE:
740
ADDRESS:1755 WEST LANCASTER BLVD.TELEPHONE:
(661) 212-7939
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:6CENSUS: 4DATE:
03/22/2024
UNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Teodoro TrippTIME COMPLETED:
11:25 AM
ALLEGATION(S):
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9
Facility staff yells at residents in care.
INVESTIGATION FINDINGS:
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On 03/22/2024 at 9:33 a.m. Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced complaint visit to this facility to investigate the above allegation. LPA met with Administrator Teodoro Tripp and explained the reason for the visit. An entrance interview was conducted.

LPA conducted a physical plant tour at 9:52 a.m., and requested copies of facility documents relevant to the investigation at approximately 10:20 a.m., LPA reviewed the following for resdient #1 (R1); resident roster, LIC500, physician's report, appraisal/needs and services plan, pre-placement appraisal and admissions agreement. LPA interviewed staff and residents between 9:52 a.m. and 10:19 a.m. Regarding the allegation, facility staff yells at residents in care, it was alleged that a staff yelled at Resident #1 (R1). LPA attempted to interview four (4) out of four (4) residents. Two (2) of four (4) residents were non verbal and unable to communicate with LPA. Interview with Resident #1 (R1) and Resident #2 (R2) denied being yelled at by staff and denied witnessing any staff yell at residents.
(Continued to LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
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-20240320161058
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: LANCASTER HAVEN RCFE
FACILITY NUMBER: 197608302
VISIT DATE: 03/22/2024
NARRATIVE
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(Continued from LIC9099)

LPA's interview with the administrator and staff #1 (S1) denied yelling at residents and denied witnessing any staff yell at residents. Furthermore, interviews with administrator and S1 revealed no resident has complained about staff yelling at them or witnessing staff yell at other residents. Based on interviews conducted the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2