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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608333
Report Date: 10/12/2022
Date Signed: 10/12/2022 04:02:48 PM

Substantiated


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: 4DATE:
10/12/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Administrator is charging above the SSI rate for an SSI resident
INVESTIGATION FINDINGS:
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LPA Spaeth conducted an unannounced visit and was greeted by caregiver. LPA stated the purpose of the visit was to present LPA's findings regarding a complaint which states administrator is charing above the SSI rate for an SSI resident. LPA conducted a facility tour and did not observe any health or safety issues.

Based upon LPA's inteviews of Resident (R1), Complainant, and Administrator, R1 was receiving SSI benefits and the Administrator requested additional money for the care of R1. LPA Spaeth received evidence that R1's family member was sending additional money to Administrator. Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency was cited (refer to LIC 809-D).

LPA Spaeth Exit interview conducted, Appeal Rights discussed, and a copy of the report was issues to Administrator.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 31-AS-20210429082130
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/12/2022
Section Cited
CCR
87464(e)
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87464 Basic Services (e) If the resident is an SSI/SSP recipient, then the basic services shall be provided and/or made avaialble at the basic rate at no additional charge to the resident. This is evidenced by:
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Administrator and LPA reviewed Regulation 87464. Administrator stated will follow the regulations and follow facility procedures..
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Based upon LPA's interview of the Administrator, reporting party, and resident (R1), the Administrator charged an additional amount above the SSI amount received by the resident.
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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: 10/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022
LIC9099 (FAS) - (06/04)
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