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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609720
Report Date: 07/22/2022
Date Signed: 07/22/2022 04:07:27 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
07/21/2022 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20220721152539
FACILITY NAME:HAVENS AT ANTELOPE VALLEY ASSISTED LIVING, THEFACILITY NUMBER:
197609720
ADMINISTRATOR:MINDY MENDOZA-PERRYFACILITY TYPE:
740
ADDRESS:43051 15TH SREET WESTTELEPHONE:
(661) 723-8525
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:115CENSUS: 79DATE:
07/22/2022
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Andrea GutierrezTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility is in disrepair (cloudy water)
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced complaint visit to investigate the allegation above. LPA met with the Business Office Manager since the Administrator was not at the facility. LPA explained the reason for this visit.

LPA conducted a brief physical plant tour from 12:45 until 1:10 pm to ensure no immediate health and safety issues were present. LPA interviewed two staff members from 1:30 until 2:00 pm. LPA viewed eight rooms from 2:00 until 3:00 pm with staff member (S1) who conducts maintenance repair work at the facility. LPA also interviewed a resident from 3:00 pm until 3:20 pm.

It is alleged that the water from the kitchen sink of one resident’s apartment was cloudy and was a grey color. LPA and S1 checked the resident’s kitchen sink water. S1 filled a glass with water and LPA observed the water in the glass was clear and not cloudy. LPA and S1 checked seven other apartments’ kitchen sink water and found the water was clear and not cloudy.


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022
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 2
Control Number 31-AS-20220721152539
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: 07/22/2022
NARRATIVE
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S1 stated two plumping companies previously checked the water pipes and due to the repair work completed, the water has been clear since that time. LPA interviewed the resident who experienced the cloudy water. The resident stated the water has been clear and not cloudy. The resident also stated it appears the water line still has air but confirmed the water is no longer cloudy. Therefore this allegation is unsubstantiated.

Exit interview conducted, appeal rights discussed, and a copy of the report was given to the Business Office Manager.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2