Incident reporting
Cited in 3 reports, with 3 deficiencies in total.
HAVENS AT ANTELOPE VALLEY ASSISTED LIVING, THE
43051 15TH SREET WEST, Lancaster CA 93534
115 bedsLatest official report Jun 15, 2026Licensed
Additional info
- Telephone
- (661) 723-8525
- Licensee
- WELLTOWER PEGASUS TENANT LLC; PSL ASSOCIATES LLC
- Administrator
- PAMELA BRADLEY
- Contact
- PAMELA BRADLEY
- License first date
- Feb 1, 2019
- License effective date
- Feb 1, 2019
- District office
- WOODLAND HILLS S.RO · (818) 596-4334
- Regional office
- 31
- Clients served
- 935 - ELDERLY
Summary
The available records show 6 Type A and 10 Type B deficiencies for this facility.
- Most recent inspection
- Mar 24, 2026
- Most recent deficiency
- May 28, 2026
1 later report, on Jun 15, 2026, recorded no deficiencies, though the records do not say whether they were follow-ups.
What Type A and Type B mean
- Type A
- 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
- Violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care.
Both classifications are published by California CDSS and are shown as published. SeniorLivingFacts does not rename them or add a severity level of its own.
At a glance
Counts cover the five-year public record. Typical figures are the median for the 212 Los Angeles County facilities licensed for 50 or more beds.
In the available public five-year record, CCLD published 42 reports for this facility: 15 inspections, 27 complaint investigations, and 0 licensing or administrative records.
Those records contain 6 Type A and 10 Type B deficiencies.
0 deficiencies have explicit official correction or clearance evidence in the loaded records.
- Official inspections
- 15
- Recorded deficiencies
- 16
- Type A deficiencies
- 6
- Type B deficiencies
- 10
- Substantiated complaints
- 10
- Repeated topics
- 1
More than the typical 7
1 in the last 12 months
Well above the typical 8
3 in the last 12 months
More than the typical 3
0 in the last 12 months
Well above the typical 5
3 in the last 12 months
Well above the typical 3
3 in the last 12 months
Last 36 months
Repeated topics
Topics cited in more than one report during the last 36 months. A repeat may show a pattern worth asking about. Each date opens its report below.
Official report history
All preserved reports from the most recent to the oldest, sortable by report type.
Complaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87415(a)(2)
- Regulation authority
- CCR
What the official deficiency says
87415 Night Supervision.(a) The following persons providing night supervision...shall be available...to assist in caring for residents in the event of an emergency...(2)employee shall be on call, and capable of responding. This requirement was not met evdienced by: Based on interviews, S2 confirmed they did not call emergency services for R1 which poses a potential Health, Safety, or Personal Rights risk to persons in care.
Official plan of correction
The Licensee/Administrator will conduct in-service training with staff including S2 and email LPA Segovia the staff training regarding policy/procedure regarding emergency services by POC due date. POC due date: 6/11/2026
Deadline recorded: Jun 11, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Jun 11, 2026
Correction not verified in available records
Complaint
Allegations1 substantiated · 1 unsubstantiated · 0 unfounded · 1 cited
Incident reportingType B
- Official classification
- Type B
- Official code
- 87211(a)(1)(D)
- Regulation authority
- CCR
What the official deficiency says
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: 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.
Official plan of correction
The Licensee will review the regulation and email LPA Segovia a statment of understanding by the POC due date.
Deadline recorded: Jan 21, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Jan 21, 2026
Correction not verified in available records
Complaint
Allegations0 substantiated · 8 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations1 substantiated · 3 unsubstantiated · 0 unfounded · 1 cited
Food serviceType B
- Official classification
- Type B
- Official code
- 87555(b)(29)
- Regulation authority
- CCR
What the official deficiency says
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: 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.
Official plan of correction
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.
Deadline recorded: Sep 19, 2025. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Sep 19, 2025
Correction not verified in available records
Complaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87303(a)(1)
- Regulation authority
- CCR
What the official deficiency says
87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary...at all times… Maintenance shall include… well-being of residents…(1)... laundry…areas shall be maintained in a clean, sanitary…condition. This requirement was not met by: Based on LPA’s observations 2 out of the 4 laundry rooms were not kept clean or in sanitary conditions which poses a potential Health, Safety, or Personal Rights risk to persons in care.
Official plan of correction
The Executive Director will email LPA Segovia photos of the new trash bins with secured lids in each laundry room, a statement of communication with residents/staff regarding proper disposal of trash and agreement of laundry rooms being checked on twice a day for cleanliness and upkeep.
Deadline recorded: Aug 20, 2025. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Aug 20, 2025
Correction not verified in available records
Complaint
Allegations0 substantiated · 2 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Medical and dental careType A
- Official classification
- Type A
- Official code
- 87465(a)(4)
- Regulation authority
- CCR
What the official deficiency says
87465(a)(4) Incidental Medical and Dental Care: The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: based on interviews and records review R1 missed medication on 03/08/24 and 03/09/24.This poses an immediate risk to the residents in care.
Official plan of correction
Executive Director agreed to hire a licensed vendor to provide medication training to all staff. Training certificates must be submitted by the POC date.
Deadline recorded: Mar 16, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 16, 2024
Correction not verified in available records
Complaint
Allegations0 substantiated · 4 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 5 unsubstantiated · 0 unfounded · investigated over 2 visits
No deficiencies recorded in this reportComplaint
Part of the complaint whose outcome is recorded on Feb 13, 2023 · Control 31-AS-20221205133217
No deficiencies recorded in this reportComplaint
Allegations1 substantiated · 4 unsubstantiated · 1 unfounded · 1 cited
Not classified in the sourceType B
- Official classification
- Type B
- Official code
- 8768.1(a)(16)
- Regulation authority
- CCR
What the official deficiency says
8768.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16) To receive or reject medical care or other services. This requirement was not met as evidenced by: Based on interviews of home health agency's staff and the facility staff member, the resident was denied access to home healthcare services. This poses an immediate health and safety risk to residents in care.
Official plan of correction
Administrator will review the screening process for guests based on PIN 24-04-ASC.
Deadline recorded: Aug 12, 2022. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Aug 12, 2022
Correction not verified in available records
Complaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations1 substantiated · 1 unsubstantiated · 0 unfounded · 1 cited
Incident reportingType B
- Official classification
- Type B
- Official code
- 87211(a)(1)(d)
- Regulation authority
- CCR
What the official deficiency says
(a)(1) a written report shall be submitted to the licensing agency & to the person responsible for the resident within seven day of the occurrence of any of the events….(d) any incident which threatens the welfare, safety or health of any resident….This requirement was not met as evidenced by: Due to LPA's review of the resident records, the review of the incident reports received from the facility, and the complainant's statement, the facility failed to report the hospitalization of the resident to both parties.
Official plan of correction
Administrator will ensure the submissions of all incident reports to CCL and will conduct training of staff regarding the required reporting procedures.
Deadline recorded: May 20, 2022. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline May 20, 2022
Correction not verified in available records
Complaint
Allegations0 substantiated · 4 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations1 substantiated · 3 unsubstantiated · 0 unfounded · 1 cited
Resident rightsType A
- Official classification
- Type A
- Official code
- 87468.2(a)(4)
- Regulation authority
- CCR
What the official deficiency says
(a)In addition to the rights listed in …, residents in.. care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, & services that meet their individual needs & are delivered by staff that are sufficient in numbers, This requirement was not met as evidenced by: Based upon LPA's interviews of the staff members, caregivers were not aware the resident had left the building without an escort, which is an immediate health and safety risk to residents in care.
Official plan of correction
The staff will ensure when outside vendors come to complete work on the faciliy, the vendors will be instructed to keep fire exit doors closed when not in the immediate vacinity. Caregivers will be instructed to regularly check fire exit doors when vendors are on the premises. Administrator will educate staff
Deadline recorded: Apr 28, 2022. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Apr 28, 2022
Correction not verified in available records
Complaint
Allegations0 substantiated · 6 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 2 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 4 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations4 substantiated · 0 unsubstantiated · 0 unfounded · 4 cited
Resident rightsType A
- Official classification
- Type A
- Official code
- 87468.1(a)(1)
- Regulation authority
- CCR
What the official deficiency says
Personal Rights of Residents in All Facilities-To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on interviews conducted it was found that S1 stole food from R1 and other staff have yelled at R1. This poses an immediate health and safety risk to residents in care.
Official plan of correction
Corrected before visit. Facility has suspended S1 and S2 was terminated from their job.
Deadline recorded: Mar 8, 2022. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 8, 2022
Correction not verified in available records
Resident rightsType A
- Official classification
- Type A
- Official code
- 87468.(a)(3)
- Regulation authority
- CCR
What the official deficiency says
Personal Rights of Residents in All Facilities-To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidenced by: Based on interviews conducted it was found that staff's actions towards R1 has caused interference with R1's eating and sleeping patterns which posed an immediate health and safety issue to residents in care.
Official plan of correction
Corrected before visit. S1 was suspended and is not allowed to work with R1.
Deadline recorded: Mar 10, 2022. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 10, 2022
Correction not verified in available records
Resident rightsType A
- Official classification
- Type A
- Official code
- 87468.1(a)(2)
- Regulation authority
- CCR
What the official deficiency says
Personal Rights of Residents in All Facilities-To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on interviews conducted it was found that after pressing their pendant R1 has had to wait more than 15 minutes on several occassions which poses an immediate health and safety risk to residents in care.
Official plan of correction
Administrator will have an in-service with staff on response times to all resident's pendants and emphasize that staff is to respond within seven minutes. Copy of in-service will be sent to LPA.
Deadline recorded: Mar 9, 2022. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 9, 2022
Correction not verified in available records
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87303(a)
- Regulation authority
- CCR
What the official deficiency says
Maintenance and Operation- The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: Based on interviews conducted R1 air conditioner was not working properly. This posed a potential health and safety risk to R1.
Official plan of correction
Corrected before visit. R1 was moved rooms.
Deadline recorded: Mar 8, 2022. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 8, 2022
Correction not verified in available records
Complaint
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87411(a)
- Regulation authority
- CCR
What the official deficiency says
87411 Personnel Requirements-General (a) facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.... This requirement was not met based upon: Facility does not have sufficient staff which resulted in residents waiting long times to receive care from staff in a reasonable time.
Official plan of correction
Staff Gutierrez has confirmed have one med tech and two caregivers during the day along with an additional part time caregiver to provide showers for those residents when needed. For the night shift, there are two caregivers. One caregiver is also a med tech who can provide medications for any residents during the night
Deadline recorded: Feb 28, 2022. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Feb 28, 2022
Correction not verified in available records
Complaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Medication handling and storageType A
- Official classification
- Type A
- Official code
- 87465(c)(2)
- Regulation authority
- CCR
What the official deficiency says
Incidental Medical and Dental Care-Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on interviews conducted it was found that five residents were not given their medications at all and twenty six residents were given their medication late which posed an immediate health and safety risk to the residents in care.
Official plan of correction
Corrected before visit. Administrator hired a new health & wellness director and two new med techs to over see medications. LPA was able to verify that the new hires have the appropriate training for the position.
Deadline recorded: Feb 14, 2022. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Feb 14, 2022
Correction not verified in available records
Complaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportSource and limits
California Department of Social Services, Community Care Licensing Division. Public facility history is described by the source as a five-year window. Older records and previous-licensee history may require a regional-office request. Type 741 RCFE-CCRCs, nursing homes, and other care settings are excluded from this page.
Read the data methodology