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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608333
Report Date: 10/28/2022
Date Signed: 10/28/2022 12:01:04 PM


Document Has Been Signed on 10/28/2022 12:01 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: 4DATE:
10/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Sean MendozaTIME COMPLETED:
09:30 AM
NARRATIVE
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LPA Spaeth 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 complete a tour of the facility. LPA Spaeth observed a two-day supply of fresh fruits and vegetables. The pantry contained a seven day supply of canned goods.
LPA observed the knives and the resident medications were locked in a kitchen cabinet.

The two bathrooms contained wash your hands sign, slip resistant mats, hand soap, and paper towels. LPA did not observe any health and safety issues. Upon speaking to the Administrator, LPA was told by Administrator had left the facility without supervision for fifteen minutes a few days ago. 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 issued to Administrator.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2022
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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Document Has Been Signed on 10/28/2022 12:01 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: 10/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/28/2022
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 and is an immediate health and safety risk to residents in care.
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Because this violation resulted in residents alone at the facility without caregiers present, an immedaite civil penalty in the amount of $500 is issued.

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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: 10/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2022
LIC809 (FAS) - (06/04)
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