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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608333
Report Date: 09/21/2021
Date Signed: 09/21/2021 02:11:16 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:MANOR HOUSE OF ANTELOPE VALLEYFACILITY NUMBER:
197608333
ADMINISTRATOR:SEAN MENDOZAFACILITY TYPE:
740
ADDRESS:45550 11TH ST., W.TELEPHONE:
(661) 951-2085
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:6CENSUS: 4DATE:
09/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Sean MendozaTIME COMPLETED:
02:15 PM
NARRATIVE
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LPA Spaeth, LPA Reed, and LPM Harris conducted an unannounced annual visit to the facility. LPA's and LPM arrived at the facility at 10:35 am. LPA observed the COVID sign at the front door and was greeted by Administrator, Sean Mendoza. LPA Spaeth observed Administrator was wearing a mask. LPA Spaeth stated the purpose of the visit and asked for total census. Administrator stated there are four residents: two residents living in the facility and two residents who are temporarily living at a rehabilitation center.

At 10:45 am LPA's and LPM began the tour of the facility with the Administrator. The tour began in the backyard. LPA Spaeth observed the side gate was not locked and all parties moved from the backyard to the front yard. LPA's observed a tool kit outside near the garage. LPM asked permission to open the tool kit at 10:52 am and all parties observed a hand saw. LPAs stated all tools must be locked in a safe area. All parties observed the Administrator locked the tool kit in the garage. All parties then entered the garage and LPA Spaeth observed a refrigerator that contained frozen meats and vegetables. LPA Spaeth also observed emergency water.

All parties then entered the facility into the living room area. Administrator unlocked a closet which contained cleaning supplies and non-perishable canned goods along with PPE supplies. Also, there was emergency supply of foods in the closet. The first aid kit is stored in the locked closet and contained tweezers and scissors. At approximately 10:55 am, LPA's observed Lysol sitting out in the living room. LPAs stated chemicals will need to be locked away for safety reasons.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MANOR HOUSE OF ANTELOPE VALLEY
FACILITY NUMBER: 197608333
VISIT DATE: 09/21/2021
NARRATIVE
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LPA Spaeth observed a locked cabinet which contained a 90 day supply of PPE including N95 masks, hospital gowns, surgical masks, gloves and hand sanitizer. All parties
observed the staff room which was locked. LPA Spaeth observed six rooms in the facility which all contained bed, linens, comforter, lamp, lamp stand, and chest of drawers. There are two bathrooms in the facility which both contained wash your hands sign, hand soap, trash can, slip resistant mat in the shower, and paper towels. LPA Spaeth observed a hallway closet which contained clean linens. LPAs observed the arrival of Administrator, Marie Mendoza at 11:00 am.

All parties observed the medications and knives locked in a kitchen cabinet. The facility contained a three day supply of perishable items such as fruits and vegetables. The kitchen also contained a seven day supply of canned goods and pasta items. At approximately 11:31 am, LPA Reed & LPA Spaeth tested the water temperature which read 121.3 F. LPAs stated to Marie Mendoza that the temperature reading was above 120.0 F. Administrator Sean Mendoza turned down the temperature on the hot water tank. At 11:55 am, LPA Reed checked the carbon monoxide detector and the detector was properly working. At 12:00 noon, Administrator Sean Mendoza checked the smoke detectors. LPA Spaeth observed three smoke detectors were not working in the dining room, office and one resident room. At 12:03 LPA Reed began the resident and staff record review. It was noted that appraisals were not done annually and during the visit, staff conducted annuals with both residents in the facility.

Under Title 22 General Regulations, the following citations were issued and recorded on the attached LIC 809D.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MANOR HOUSE OF ANTELOPE VALLEY
FACILITY NUMBER: 197608333
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/21/2021
Section Cited

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Maintenance & Operation 87303(2) Faucets used by residents for personal care ... shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
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This was not met based upon: At approximately 11:31 am, LPA Reed and LPA Spaeth tested the water temperature in bathroom one which read 121.3 F
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Type A
09/21/2021
Section Cited

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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times.
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This was not met based upon: At 10:52 am, LPA's observation, a unlocked toolkit was observed in the front yard and contained a hand saw.
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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.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MANOR HOUSE OF ANTELOPE VALLEY
FACILITY NUMBER: 197608333
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/21/2021
Section Cited

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87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
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This was not met based upon: At approximately 10:55 am, LPA's obsered a can of Lysol spray sitting in the living room.
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Type A
09/21/2021
Section Cited

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87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
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This was not met based upon: At 12:00 pm, Administrator Sean Mendoza checked the smoke detectors. LPA Spaeth observed three smoke detectors were not working in the dining room, office and one resident room.
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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.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4