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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609720
Report Date: 11/01/2024
Date Signed: 11/01/2024 02:01:30 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
10/25/2024 and conducted by Evaluator Nicholas Reed
COMPLAINT CONTROL NUMBER: 31-AS-20241025121758
FACILITY NAME:HAVENS AT ANTELOPE VALLEY ASSISTED LIVING, THEFACILITY NUMBER:
197609720
ADMINISTRATOR:KATHERINE ALEMANFACILITY TYPE:
740
ADDRESS:43051 15TH SREET WESTTELEPHONE:
(661) 723-8525
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:115CENSUS: 82DATE:
11/01/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Katherine AlemanTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff do not provide residents with activities
INVESTIGATION FINDINGS:
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At approximately 11:00 a.m. on 11/01/24 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and later the administrator and disclosed the reason for the visit.

To investigate the allegations above, LPA interviewed staff and residents between 11:00 a.m. and 1:00 p.m. today, conducted a record review of pertinent records, including but not limited to staff and client rosters, activity schedules, and facility notices at 11:30 a.m., and toured the facility inside and out at 11:45 a.m.

Regarding the allegation "Staff do not provide residents with activities" it was alleged that the facility does not provide the residents with activities, specifically that arts and crafts and rides to outings are not provided. From the facility tour, LPA observed a resident returning from an outing around 11:30 a.m. in the facility van.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
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-20241025121758
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HAVENS AT ANTELOPE VALLEY ASSISTED LIVING, THE
FACILITY NUMBER: 197609720
VISIT DATE: 11/01/2024
NARRATIVE
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At approximately 11:40 a.m., LPA observed five (05) residents playing cards, two (02) residents playing a board game, and two (02) residents engaged in arts and crafts in the activity room. LPA also observed sufficient supplies of paper, colored pencils, pens, beads, and strings in the activity room. The upstairs activity area contained a pool table, puzzles, and a library of reading material. Paper and digital activity schedules were posted near the main entrance. Activity postings throughout the facility notified residents of holiday festivities. LPA also observed the daily facility newspaper and a drop box for residents to schedule use of the facility van for appointments and activities. Interviews with eight (08) out eight (08) residents today confirmed the facility provides adequate activities to their likings. Interview with Resident #1 (R1) at 12:00 p.m. revealed they have played cards with other residents for the past fifteen (15) years at the facility. Interview with Resident #2 (R2) at 12:30 p.m. revealed the facility provides more than enough art supplies for their daily activities. Interview with the administrator at 11:30 a.m. revealed the facility van has always been functional and the facility recently introduced scenic drives into their activity program. Interview with Staff #1 (S1) at 12:45 p.m. revealed residents and their families enjoy the billiards table, daily newspaper, and holiday activities. Based on observations, interviews, and record review, the facility provides residents with activities and accommodates sufficient space for activities. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Exit interview conducted. Copy of report provided.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2