<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609720
Report Date: 09/13/2025
Date Signed: 09/13/2025 02:41:52 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
02/07/2025 and conducted by Evaluator Angelica Segovia
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20250207120648
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: 101DATE:
09/13/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Christine Ellis- Community Sales Director TIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not administer medication as prescribed resulting in death.
Staff did not prevent the facility from being unsanitary.
Staff are serving uncooked foods to residents.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 9/13/2025 at approximately 1:30 PM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced subsequent complaint visit to the facility. LPA was greeted by the Community Sales Director, Christine Ellis and stated the reason for their visit was to deliver the findings of the complaint. The Executive Director, Katherine Aleman was unavailable to assist with today's visit and designated the Community Sales Director to sign today's report.

To investigate the allegation(s), on 7/19/2025 at approximately 10:00 AM, LPA conducted a physical plant tour. By 11:00 AM, LPA requested relevant documentation. From 11:30 AM to 3:30 PM, LPA attempted interviews with ten (10) residents (R2-R11), nine (9) staff members (S1-S9) and conducted record review.


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

DATE: 09/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2025
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 6
Control Number 31-AS-20250207120648
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: 09/13/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding the allegation: Staff did not administer medication as prescribed resulting in death. It was alleged that S2 did not administer R1’s medication accordingly resulting in death. To investigate the allegation, LPA attempted interviews with four (4) staff members and conducted a record review of R1’s medical records. LPA’s interview with three staff members stated that they have not witnessed nor heard of any residents being over-medicated. LPA attempted to interview S2 but S2 was on leave and could not be contacted. LPA’s record review of R1’s Centrally Stored Destruction Medication Record (CSDMR) noted that on 7/25/2024 (the day prior to R1’s passing) R1 was not assisted with medication by S2. Further review showcased that S2 had not assisted R1 with their medication since 7/19/2024. LPA’s review of S2’s file revealed that S2 had been demoted at the end of July 2024 from Medication Technician (Med Tech) to Care Partner due to various disciplinary incidents, however, no medication errors were documented.

Further review of R1’s medical record revealed that R1 had been placed under the care of Caremark Healthcare Hospice services from 7/02/2024 to 7/26/2024, following a medical diagnosis of terminal illness with a life expectancy of less than six months. Additionally, R1’s Certificate of Death listed R1’s leading cause of death to be a result of Cardiopulmonary Arrest. Also, R1’s decline of health was documented during various visits from hospice care. On 7/23/2024 the Hospice service visit documented, R1 was observed to be within their, “…transitioning” period.

Based on interviews and record review, there is not enough information to verify the allegation, therefore, the allegation is UNSUBSTANTIATED at this time.

Regarding the allegation: Staff did not prevent the facility from being unsanitary. It was alleged that the facility’s kitchen and bathrooms are left in unsanitary conditions. To investigate the allegation, LPA attempted interviews with ten (10) residents and four (4) staff members. LPA’s interview with nine (9) out of the ten (10) residents revealed that they have not seen the bathrooms dirty. Interview with R3 stated that the bathrooms, “…are cleaned regularly”. LPA attempted to interview R11 but they declined to be interviewed. LPA’s interview with S1 and S7 confirmed that the bathrooms are cleaned daily. Interview with S7 revealed that the bathrooms are cleaned throughout each shift and if, “…there is an accident, they call us and we take care of it”. Regarding the kitchen, LPA’s interview with S6 revealed the kitchen is cleaned… “every day… multiple times a day”. LPA’s record review of the Kitchen’s Daily Cleaning Schedule confirmed a morning and night schedule of various cleaning tasks kept and documented. During LPA’s physical plant tour, LPA observed all publicly accessible bathrooms to be clean and in sanitary conditions.

(Continue to LIC 9099-C)

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

DATE: 09/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 31-AS-20250207120648
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: 09/13/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
During LPA’s observation of the kitchen, LPA observed the kitchen to be clean and free from pests. LPA observed kitchen staff washing pots and dishes after use. LPA observed the stove and kitchen appliances to be clean and in proper condition.

Based on interviews, record review and observation, the facility’s bathrooms and kitchen were observed to be in sanitary conditions. Therefore, the allegation is UNSUBSTANTIATED at this time.

Regarding the allegation: Staff are serving uncooked foods to residents. It was alleged that staff are serving uncooked food to residents. To investigate the allegation, LPA interviewed nine (9) residents and four (4) staff members. LPA’s interview with all residents revealed that they have never been served uncooked meat by staff. LPA’s interview with R6 revealed that they have never been served uncooked meat and that, “…the food is delicious”. LPA’s interview with S9 revealed that the meat is checked with a cooking thermometer to ensure the meat has reached a safe and desired temperature prior to being served to the residents. During LPA’s physical plant tour, LPA observed a cooking thermometer and kitchen appliances to be in proper working conditions. LPA observed food preparation stations to be clean. LPA observed a variety of food being prepared for consumption. LPA observed the food being served to be edible and not appear uncooked.

Based on interviews and observation, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Community Sales Director.

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

DATE: 09/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
02/07/2025 and conducted by Evaluator Angelica Segovia
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20250207120648

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: 101DATE:
09/13/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Christine Ellis- Community Sales Director TIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure that dishes are cleaned.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 9/13/2025 at approximately 1:30 PM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced subsequent complaint visit to the facility. LPA was greeted by the Community Sales Director, Christine Ellis and stated the reason for their visit was to deliver the findings of the complaint. The Executive Director, Katherine Aleman was unavailable to assist with today's visit and designated the Community Sales Director to sign today's report.

To investigate the allegation(s), on 7/19/2025 at approximately 10:00 AM, LPA conducted a physical plant tour. By 11:00 AM, LPA requested relevant documentation. From 11:30 AM to 3:30 PM, LPA attempted interviews with ten (10) residents (R2-R11), nine (9) staff members (S1-S9) and conducted record review.


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

DATE: 09/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2025
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 6
Control Number 31-AS-20250207120648
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: 09/13/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding the allegation: Staff did not ensure that dishes are cleaned. It was alleged that the facility’s ice machine and dishes served to residents are not cleaned. To investigate the allegation, LPA conducted a physical plant tour of the kitchen, LPA observed a variety of dishes and utensils to be clean and washed properly. In the dining room, LPA observed a variety of plates, utensils and cups to be clean and in sanitary conditions. However, during LPA’s review of the facility’s Ice Machine Cleaning Log, it was revealed that the cleaning of the ice machine had not been documented since April of 2025. LPA’s interview with S8 stated that the ice machine is to be, “cleaned monthly but it hasn’t been cleaned…”.

Based on interviews, observation and record review, the facility has failed to keep the ice machine properly clean, therefore the allegation is SUBSTANTIATED at this time.

Citation issued, please refer to 9099-D.

No other immediate health and safety hazards observed during the time of the visit.

Exit interview conducted, Appeal Rights given, and a copy of this report was provided to the Community Sales Director.

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

DATE: 09/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 31-AS-20250207120648
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/19/2025
Section Cited
CCR
87555(b)(29)
1
2
3
4
5
6
7
87555 General Food Service Requirements (b) The following food service requirements shall apply....(29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair....

This requirement was not met by:
1
2
3
4
5
6
7
The Licensee will create a monthly cleaning list log which includes the cleaning of the ice machine. Additionally, The Licensee will review the monthly cleaning log to ensure the ice machine and other equipment are maintained in clean and safe conditions.
8
9
10
11
12
13
14
Based on LPA's interviews, record review and observation of the Ice Machine Cleaning Log, the ice machine had not been cleaned since April of 2025 which poses a potential Health, Safety, or Personal Rights risk to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6