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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609720
Report Date: 07/29/2025
Date Signed: 07/29/2025 02:44:16 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.RO, 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
07/23/2025 and conducted by Evaluator Angelica Segovia
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20250723151134
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: 105DATE:
07/29/2025
ANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Katherine Aleman-Executive DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff are leaving residents in soiled clothing for extended periods of time.
Staff are not meeting residents toileting needs.
INVESTIGATION FINDINGS:
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On 7/29/2025 at approximately 10:00 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced initial complaint visit to the facility. LPA was greeted by the Executive Director, Katherine Aleman and stated the reason for their visit was to conduct interviews, review documentation and deliver the findings of the complaint.


To investigate the allegation(s), at approximately 10:30 AM, LPA conducted a physical plant tour. By 11:30 AM, LPA requested relevant documentation. From 11:30 AM to 2:30 PM, LPA attempted interviews with eleven (11) residents (R1-R11), seven (7) staff members (S1-S7) and conducted record review.

(Continue to 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
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 3
Control Number 31-AS-20250723151134
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HAVENS AT ANTELOPE VALLEY ASSISTED LIVING, THE
FACILITY NUMBER: 197609720
VISIT DATE: 07/29/2025
NARRATIVE
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Regarding the allegation: Staff are leaving residents in soiled clothing for extended periods of time. It was alleged that residents were left unattended for hours causing them to urinate all over themselves. To investigate the allegation, LPA attempted interviews with eleven (11) residents and seven (7) staff members. LPAs interview with six (6) residents revealed that staff have never left them soiled for extended periods of time. Interview with R2 stated, “…I just push my button and they will come to change me”. Interview with R5 stated that the staff do not let them stay soiled, “…they don’t let me…the staff is great”. LPA attempted to interview R7-R11 but they were asleep during the time of the visit. LPA’s interview with five (5) staff members confirmed that residents are checked on hourly to ensure their incontinent needs are being met. Interview with S4 and S5 revealed that they have witnessed R2 and R5 being left soiled. LPA’s record review of R2 and R5’s Care Rounds revealed that both residents have had documented refusals of not allowing staff to assist them.

During LPA’s physical tour, LPA conducted room checks of residents listed under incontinence care. In the memory care unit, LPA toured five (5) bedrooms and in the assisted living unit, LPA toured eleven (11) rooms. LPA observed the residents to be clean, well-groomed and did not experience any malodor. LPA did not witness any leak pads left soiled. LPA observed residents’ chairs, beds and flooring to be clean and in proper condition. LPA witnessed staff members conducting their rounds and assisting residents.

Based on LPA’s interviews, record review and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Regarding the allegation: Staff are not meeting residents toileting needs. It was alleged that residents’ incontinence needs are not being met by staff. To investigate the allegation, LPA attempted interviews with eleven (11) residents and five (5) staff members. LPA’s interview with six (6) residents revealed that staff do meet their toileting needs. Interview with R1 stated the staff keep them, “clean and dry”. Interview with R6 stated that they will push their button and staff will assist them with their toileting needs. LPA attempted to interview R7-R11 but they were asleep during the time of the visit. LPA’s interview with all staff members confirmed that residents who have incontinent needs are checked on to ensure their toileting needs are being met. During LPA’s physical plant tour, LPA observed residents to appear in good health. LPA observed residents to be clean and well-groomed. LPA did not experience any malodors within the facility.

(Continue to 9099-C)

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20250723151134
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HAVENS AT ANTELOPE VALLEY ASSISTED LIVING, THE
FACILITY NUMBER: 197609720
VISIT DATE: 07/29/2025
NARRATIVE
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Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No immediate health and safety issues observed during the day of the visit. Exit interview conducted and a copy of this report was provided to the Executive Director.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3