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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608333
Report Date: 03/11/2022
Date Signed: 03/11/2022 01:48:13 PM


Document Has Been Signed on 03/11/2022 01:48 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
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:
03/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Sean MendozaTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Michael Cava conducted a Case Management (CM) visit to the facility to follow up on an incident regarding a possible discrepancy with facility operation. LPA also checked to insure that care and supervision is not being interrupted. During the course of the visit, LPA met and interviewed the administrator, Sean Mendoza, interviewed residents and staff, and checked staffing to insure there is sufficient coverage. LPA also conducted a tour of the physical plant to insure the health and safety of the residents in care and that there is sufficient perishable and non-perishable food.

Per inspection of the physical plant, there was no immediate health and safety issue present during the visit. LPA observed adequate supervision for the residents in care and no interruption with facility operation. Furthermore, Mr. Mendoza is continuing to oversee the facility operation.

Pursuant to title 22, division 6, chapter 8, facility is compliant to regulation. No citations issued at this time.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022
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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