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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608333
Report Date: 09/08/2022
Date Signed: 09/13/2022 10:25:15 AM


Document Has Been Signed on 09/13/2022 10:25 AM - 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: 3DATE:
09/08/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Sean MendozaTIME COMPLETED:
11:30 AM
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LPA Spaeth arrived to the facility and was greeted by the caregiver. LPA stated the purpose of the visit was to conduct a tour of the facility. LPA observed the caregiver was wearing a mask. LPA conducted a tour of the facility and observed the knives were locked in the cabinet. There was an adequate supply of fresh vegetables and meats in the refrigerator. The resident medications were safely locked in the hall closet. LPA observed the facility was clean.

The bathrooms were also clean and contained wash your hands sign, hand soap, paper towels, and a trash can. LPA observed three residents rooms and observed all three rooms were neat and clean. The Administrator arrived at 11:25 am.

There are no deficiencies to report at this time. Exit interview conducted, and appeal rights discussed.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022
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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