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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608333
Report Date: 09/22/2022
Date Signed: 09/22/2022 03:49:38 PM


Document Has Been Signed on 09/22/2022 03:49 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: 3DATE:
09/22/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Sean MendozaTIME COMPLETED:
10:48 AM
NARRATIVE
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LPA Spaeth, LPA Reed, and Ombudsman Williams conducted an unannounced visit and was greeted by
Administrator. LPA's temperature was taken and recorded. LPA stated the purpose of the visit was to do a tour of the facility. LPA did not observe any health and safety issues.

Upon speaking to the Administrator, LPAs were told the Administrator had left the facility without supervision this morning for fifteen minutes.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency is cited (refer to LIC 809-D).

Exit interview conducted, Appeal Rights discussed, and a copy of the report was issues to Administrator.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022
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 2


Document Has Been Signed on 09/22/2022 03:49 PM - It Cannot Be Edited

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: 09/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/23/2022
Section Cited

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1548(b)(3) The department shall assess an immediate civil penalty of five hundred dollars per violation and...($100) for each day the violation continues after citation for any of the following serious violations (3) Absence of supervision as required by status or regulation
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This requirement was not met based upon Administrator's statement had left the facility without supervision, the allegation is substantiated & is an immediate health & safety risk to residents in care.
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Because this violation resulted in residents alone at the facility without caregivers present, an immdiate civil penalty in the amount of $500 is issued.
Type A
09/23/2022
Section Cited

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87761(d) When a facility is cited for a deficiency & violates the same regulation subsection within 12 month period, the facility shall be cited & an immediate penalty of $150 per cited violation shall be assessed for one day only...This requirement was not met based upon:
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Previous Complaint #31-S-20220912170014 was substantiated on 9/12/2022 with the same allegation, lack of care and supervision for the residents.
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Because this violation resulted in residents along at the facility without caregivers present, an immdiate civil penalty in the amount of $500 is issued.
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: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2