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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608333
Report Date: 10/12/2022
Date Signed: 10/12/2022 03:55:09 PM


Document Has Been Signed on 10/12/2022 03:55 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:
10/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Sean MendozaTIME COMPLETED:
01:30 PM
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LPA Spaeth conducted an unannounced annual visit and was greeted by Administrator and caregiver. Administrator confirmed there are three residents at the facility. LPA observed the caregiver and Administrator were both wearing masks.

LPA observed the sign in station at the front door which contained sign in sheet, hand sanitizer and a thermometer. Administrator recorded LPA's temperature and LPA observed the sign in station at the entry to the facility.

LPA observed the living room contained comfortable seating. The dining room and kitchen are combined. LPA observed the dining room table with dining room chairs. LPA observed the knives and medications were locked in a kitchen cabinet. LPA observed the cleaning supplies were locked underneath the kitchen sink. LPA observed a seven day supply of canned goods in the pantry and a two day supply of fresh fruits and vegetables in the refrigerator.

LPA observed the residents' rooms contained bed, linens, lamp, and night stand. There are two bathrooms in the room which contains wash your hands sign, hand soap, paper towels and a trash can. Also, there is a hallway closet which contains clean linens.

LPA observed there are COVID signs posed throughout the facility. The gate that leads away from the property was not locked. LPA observed the backyard has seating. LPA observed the smoke detectors were working.

There are no deficiencies to report at this time. Exit interview conducted, appeal rights discussed, and a copy of the report was given to the Administrator.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2022
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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