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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608333
Report Date: 09/08/2022
Date Signed: 10/12/2022 11:15:19 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/29/2021 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20210429082130
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
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Sean MendozaTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
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5
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7
8
9
Resident is being improperly evicted.
Facility staff are not properly addressing R1's sleep needs.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
LPA Spaeth conducted an unannounced visit and was greeted by caregiver. LPA stated the purpose of the visit was to complete the investigation of the allegations, resident is being improperly evicted, administrator is charging above the SSI rate for an SSI resident, facilty staff are not properly addressing R1's sleep needs.
LPA conducted a tour of the facility and did not observe any immedaite health or safety issues.

LPA Spaeth interviewed resident from 11:30 am until 11:45 am. In regard to resident is being improperly evicted, this allegation is unsubstantiated. LPA interviewed the resident who stated Administrator had rescinded the eviction notice and LPA confirmed the eviction notice was rescinded. In regard to facility staff are not properly addressing R1's sleep needs, LPA observed resident has own room. LPA interviewed resident who stated since have own room, is able to sleep. This allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
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