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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609720
Report Date: 01/14/2026
Date Signed: 01/14/2026 02:04:37 PM

Substantiated


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
01/05/2026 and conducted by Evaluator Angelica Segovia
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20260105144832
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: 104DATE:
01/14/2026
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Penda Ebondy Hodges- Health and Wellness DirectorTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Staff did not report an incident involving resident as necessary.
INVESTIGATION FINDINGS:
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On 1/14/2026 at approximately 9:10 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced initial complaint visit to the facility. LPA was greeted by the Health and Wellness Director, Penda Ebondy Hodges and stated the reason for their visit.


To investigate the allegation(s), at approximately 9:30 AM, LPA conducted a physical plant tour. By 10:00 AM, LPA requested relevant documentation. From 10:00 AM to 1:30 PM, LPA attempted to interview six (6) staff members (S1-S6), one (1) resident (R1) 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: 01/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2026
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 5
Control Number 31-AS-20260105144832
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: 01/14/2026
NARRATIVE
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Regarding the allegation: Staff did not report an incident involving resident as necessary. It was alleged that staff did not report an incident involving R1 and an unknown staff member (S5). To investigate the allegation, LPA attempted interviews with five (5) staff members and one (1) resident. LPA’s interview with S2 revealed on 1/01/2026, R1’s Responsible Party informed them of an incident regarding R1 and an unknown caregiver (S5). S2 stated they were informed that when S5 attempted to transfer R1 to their desk chair, R1 lost balance and their face landed on a bin located on top of their desk. When S2 questioned if R1 had fallen, they were told no. LPA’s interview with S4 revealed that on 1/02/2026, R1’s additional Responsible Party reported to them that R1 had in fact fallen on 1/01/2026 and hit the side of their head on the bin when S5 was transferring them to their desk, resulting in them not appearing to act like oneself. Per S4, they asked R1 if they wanted to go to the hospital but R1 refused. S4 disclosed to R1’s additional Responsible Party that they would be placed on a Head Injury Monitoring Chart and if any symptoms were to change, they would be sent to the hospital. When LPA questioned S4 if they had reported the incident to Community Care Licensing Division (CCLD) they stated, “No”. LPA’s interview with S1 revealed when they became aware of the incident involving R1 they identified the caregiver at the time to be S5. When questioned whether the facility had submitted an incident report to CCLD they too stated, “No”. LPA’s interview with S5 denied R1 had fallen nor hit their head when they assisted them to their chair. LPA’s interview with R1 revealed that on 1/01/2026 a caregiver (whom they could not name) had assisted them to their chair when they lost their balance and hit the side of their head on a bin located on their desk. When questioned if they had reported the incident, R1 stated they reported to staff what had occurred on 1/02/2026. LPA’s record review of the facility’s Unusual Incident/Injury Report (SIR) confirmed CCLD did not receive a SIRs pertaining to R1’s incident on 1/01/2026.

Based on interviews and record review, the facility did not report R1’s incident of 1/01/2026 to CCLD, therefore the allegation is SUBSTANTIATED at this time.

Citation issued, Please refer to LIC 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 Health and Wellness Director.

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

DATE: 01/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20260105144832
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: 01/14/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/21/2026
Section Cited
CCR
87211(a)(1)(D)
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87211 Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports as...the following:...(1) A written report shall be submitted to the licensing agency...(D) Any incident which threatens the welfare, safety or health of any resident,...
This requirement was not met by:
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The Licensee will review the regulation and email LPA Segovia a statment of understanding by the POC due date.
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Based on interviews and record review, staff did not report an incident pertaining to R1 on 1/01/2026 to CCLD which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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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: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
01/05/2026 and conducted by Evaluator Angelica Segovia
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20260105144832

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: 104DATE:
01/14/2026
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Penda Ebondy Hodges- Health and Wellness DirectorTIME COMPLETED:
02:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not seek medical attention for resident as necessary.
INVESTIGATION FINDINGS:
1
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3
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5
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On 1/14/2026 at approximately 9:10 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced initial complaint visit to the facility. LPA was greeted by the Health and Wellness Director, Penda Ebondy Hodges and stated the reason for their visit.


To investigate the allegation(s), at approximately 9:30 AM, LPA conducted a physical plant tour. By 10:00 AM, LPA requested relevant documentation. From 10:00 AM to 1:30 PM, LPA attempted to interview six (6) staff members (S1-S6), one (1) resident (R1) 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: 01/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2026
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 5
Control Number 31-AS-20260105144832
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: 01/14/2026
NARRATIVE
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Regarding the allegation: Staff did not seek medical attention for resident as necessary. It was alleged that staff did not seek medical attention for R1 due to an incident on 1/01/2026. To investigate the allegation, LPA attempted interviews with five (5) staff members and one (1) resident. LPA’s interview with both S3 and S4 revealed when they became aware of the incident pertaining to R1, where they may have hit their head when being transferred to their desk by S5, R1 refused medical treatment. Both S3 and S4 stated R1 was placed on a Head Injury Monitoring chart for no less than 72 hours following the alleged incident to ensure the health and safety of the resident. LPA’s interview with R1 confirmed their refusal of medical treatment on 1/02/2026. LPA’s record review confirmed R1’s Head Injury Monitoring chart to be dated 1/02/2026 to 1/05/2026, as well as R1’s refusal of Emergency Transport and Care form with their signature.

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

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

Exit interview conducted and a copy of this report was provided to the Health and Wellness Director.

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

DATE: 01/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5