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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608333
Report Date: 09/09/2022
Date Signed: 09/13/2022 10:25:42 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:
09/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Sean MendozaTIME COMPLETED:
02:12 PM
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LPA Spaeth completed an unannounced visit and was greeted by the caregiver. LPA stated the purpose of the visit was to ensure the facility phone was working. LPA explained had called the facility phone number but there was no answer. Caregiver stated had been at the facility since 7:00 am and had not received any phone calls.

At 1:35 pm, Caregiver checked the phone and observed the ringer had been turned off. At 1:40 pm, LPA called the facility phone number, 661-951-2085 and the phone did ring. Caregiver stated will continue to check each day to ensure phone is properly working.

The Administrator arrived to the facility at 2:45 pm and LPA stressed when the Administrator leaves the facility, Administrator will need to make sure the caregiver will be instructed to answer all calls to the facility.

Exit interview conducted, appeal rights discussed, and a copy of the report was given to Administrator.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022
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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