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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609720
Report Date: 03/24/2026
Date Signed: 03/24/2026 02:54:38 PM

Document Has Been Signed on 03/24/2026 02:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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, THEFACILITY NUMBER:
197609720
ADMINISTRATOR/
DIRECTOR:		PENDA E HODGESFACILITY TYPE:
740
ADDRESS:43051 15TH SREET WESTTELEPHONE:
(661) 723-8525
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 115CENSUS: 94DATE:
03/24/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Penda Hodges- AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
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On 3/24/2026 at approximately 09:45 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced annual visit to the facility. LPA was greeted by staff and stated the reason for their visit. The Administrator, Penda Hodges along with the Operational Specialist, Latanya Jules assisted with today’s visit.

LPA asked for the census, Staff/Resident Roster and Liability Insurance. LPA conducted a physical plant tour at approximately 01:00 PM and the following was noted:

The facility is a two-story building with an Assisted Living unit located on both floors and a Memory Care unit located on the first floor. The facility is currently occupying ninety-four (94) residents. The facility has an approved fire clearance for one hundred fifteen (115) Ambulatory/non-ambulatory and/or bedridden residents. Hospice waiver approved for twenty (20).

Common areas: The common areas were observed to be neat, clean and organized. Such included are: Dining room, Activity room, Theater/Chapel, Mail room and Beauty Parlor. The rooms were observed to be properly furnished and in good repair. The facility maintains a comfortable temperature at 75°F. The hallways and passageways were observed to be free of obstruction. The stairways were observed to be equipped with evacuation chairs. LPA observed there to be two (2) elevators which were observed to be functional. The fireplace was observed to be covered and inaccessible to residents. LPA observed multiple fire extinguishers to be located throughout the facility on both floors and dated 2/03/2026.

LPA observed required postings such as Long-Term Care Ombudsman, See/Say Something and facility’s license to be located throughout the common areas.

Office/Work Station: The Administrative offices were observed to be located near the main entrance, near the front desk. (continued on LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Angelica Segovia
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/24/2026
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Kitchen: The kitchen was observed to be clean and free from pests. The kitchen was observed to be a commercial kitchen with a variety of commercial-grade appliances and fixtures such as but not limited to: high-capacity gas ranges, convection ovens, fryers and stainless steal prep tables. LPA observed the kitchen appliances to be working and in proper condition. Sufficient supplies of seven (7) day nonperishable foods and two (2) day perishable foods were observed. The cleaning solutions/toxins were observed to be kept in a locked storage closet. (continued on LIC 809-C)

Surrounding Grounds: The Memory Care unit is located on the first floor with thirteen (13) rooms and a capacity of eighteen (18) residents. LPA observed both dining room and living room to be in good repair and free of obstructions. LPA observed delayed egress to be in good repair and working condition. Outside of the memory care, LPA observed there to be an enclosed courtyard with an open space Gazebo. The outside area of the Assisted Living unit was observed to be equipped with a gazebo and sufficient shaded areas with outdoor furniture for residents. There is no body of water located in the facility.

Laundry Room: There are four (4) laundry rooms. One (1) commercial laundry room was observed to be located on the first floor, besides the medication room. LPA observed the commercial laundry room to be kept locked. There is an additional comunity laundry room located on the first floor. There are two (2) community laundry rooms located on the second floor for residents to use. LPA observed the community laundry rooms to be accessible to residents, but no detergents or cleaning supplies were accessible.

Bathrooms: LPA observed a total of four (4) public restrooms. Three (3) located on the first floor and one (1) located on the second floor. The bathrooms were checked for cleanliness and proper operation. The hot water temperature was measured within regulations. LPA observed appropriate grab rails and slip-resistant mats to be in proper condition.

Bedrooms: The Residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lighted appropriately. The bathrooms within the residents’ rooms were checked for cleanliness and proper operation. LPA observed appropriate grab rails and slip-resistant mats to be in proper condition. The hot water temperature was measured at a range of 116.4°F-120°F.

Medication Room: LPA observed the medication room to be located on the first floor and to be kept locked, inaccessible to residents. The medication usage was observed to be recorded and stored properly. LPA along with the Business Office Director, Ashley Lopez conducted a review of the medication to ensure compliance. First-aid kit was observed. (continue to LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Angelica Segovia
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/24/2026
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Smoke detectors and carbon monoxide: The facility was last inspected for maintenance and operational use of their automatic sprinkler system on 10/01/2025. The facility was last inspected for maintenance and operational use of all fire alarms on 10/01/2025. The last Fire Drill was conducted on 02/27/2026 where the smoke detectors and carbon monoxides were documented to be working properly and tested.

Residents/Staff Records: LPA conducted a complete file review of nine (9) resident records. Resident records appeared to be complete. Staff records: LPA conducted a complete file review of six (6) staff records. Staff records appeared to be complete and updated.

There were no immediate health and safety hazards observed during the day of inspection.

Exit interview was conducted and a copy of this report was provided to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Angelica Segovia
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
LIC809 (FAS) - (06/04)
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