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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609720
Report Date: 05/12/2022
Date Signed: 05/13/2022 08:34:42 AM

Substantiated


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
02/17/2021 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20210217111409
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: 84DATE:
05/12/2022
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Mindy Mendoza-Perry TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility did not notify authorized representative about hospital visit
Facility is not providing access to medical records to authorized representative
INVESTIGATION FINDINGS:
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LPA Spaeth conducted an announced visit and was greeted by the Administrator, Mindy Mendoza-Perry. Upon arrival LPA's temperature was recorded and COVID questions were completed. LPA stated the purose of the visit was to complete the investigation of a complaint which states facilidy did not notify authorized representative about hospital visit and facility is not providing access to medical records to authorized representative.

LPA conducted a brief tour of the facility from 9:45 am until 10:15 am and LPA did not observe any health and safety issues. LPA observed all staff members were wearing a mask.

LPA interviewed current and previous staff members from 11:00 am until 12:00 pm. LPA also reviewed resident's files from 12:20 pm unntil 12:45 pm.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
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-20210217111409
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: 05/12/2022
NARRATIVE
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In regard to the allegation facility did not notify authorized representative about hospital visit, this allegation is substantiated. LPA reviewed the resident's records and observed the complainant is documented as the authorized representative which is noted on the Admissions Agreement. Also, the Power of Attorney for the resident states the complainant was appointed as the resident's agent (attorney-in-fact). LPA reviewed all incident reports received from the facility during 2021. However, an incident report was not sent to CCL regarding the hospitalization of the resident. Also, LPA interviewed current staff and previous staff who stated did not know if the family member was notified regarding the hospitalization of the resident.

Deficiency is cited on LIC 9099 D. Appeal rights were discussed, exit interview conducted, and a copy of the report was given to the Administrator.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20210217111409
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: 05/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2022
Section Cited
CCR
87211(a)(1)(d)
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(a)(1) a written report shall be submitted to the licensing agency & to the person responsible for the resident within seven day of the occurrence of any of the events….(d) any incident which threatens the welfare, safety or health of any resident….This requirement was not met as evidenced by:

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Administrator will ensure the submissions of all incident reports to CCL and will conduct training of staff regarding the required reporting procedures.
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Due to LPA's review of the resident records, the review of the incident reports received from the facility, and the complainant's statement, the facility failed to report the hospitalization of the resident to both parties.
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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.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
02/17/2021 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20210217111409

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: DATE:
05/12/2022
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Mindy Mendoza-Perry TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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The allegation, facility is not providing access to medical records to authorized representative is unsubstantiated. LPA interviewed the Office Manager who stated the facility received a request from the complainant's attorney asking for resident documentation. The documentation was sent to the complainant's attorney via fax and Office Manager confirmed this was sent to the attorney.

Exit interview conducted, appeal rights discussed, and a copy of the report was given to the Administrator.
INVESTIGATION FINDINGS:
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Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4