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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608333
Report Date: 11/03/2022
Date Signed: 11/08/2022 09:22:28 AM


Document Has Been Signed on 11/08/2022 09:22 AM - 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:
11/03/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Staff Not AvailableTIME COMPLETED:
10:15 PM
NARRATIVE
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LPA Melissa Spaeth and LPA Nicholas Reed arrived to the facility at 2:30 pm to conduct an unannounced visit regarding Complaint #31-AS-20221102163625 and Complaint #31-AS-20221102144232 . LPAs were informed by a resident (R1) that at approximately 1:45 pm, Administrator called 911 requesting immediate assistance to the hospital. At approximately 2:15 pm, Administrator left the facility and there were no staff members present at the facility.

LPAs interviewed the four residents and residents stated there were no health or safety issues to report to CCL. LPAs immediately reported the incident to LPM Harris at 2:45 pm. LPAs toured the facility and addressed with LPM some concerns regarding the well being of the residents. During the tour, LPA's observed the following:

- The facility did not contain an adequate supply of food. LPA Spaeth observed there was not a two-day supply of fresh vegetables and the pantry only contained six cans of vegetables.
- There was dog feces and dog urine throughout the facility and the blind in the staff room was broken.
- Four resident files were missing.
- The Administrator and staff were not present at the facility

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 given to the Administrator,
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022
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 5


Document Has Been Signed on 11/08/2022 09:22 AM - 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: 11/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/10/2022
Section Cited

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87555 General Food Service Requirements (b) The following food service requirements shall apply (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
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Observations made during the tour of the facility on 11/03/2022 revealed licensee does not have a sufficient 2-day supply of perishable food & a 7-day supply of non-perishal foods which is a potential health risk to residents in care.
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Type B
11/10/2022
Section Cited

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80087(a) Buildings and Grounds. The facility shall be kept clean, sanitary and in good repair at all times. This requirement is not met as evidenced by:
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During visit LPA observed the following: 1. blind broken in staff room. 2. Dog feces throughout the facility 3. Living room furniture was dirty (4) Administrator office smelled of dog urine and dog feces which is a potential health and safety risk to residents in care.
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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: 11/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 11/08/2022 09:22 AM - 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: 11/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/10/2022
Section Cited

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87464 Basic Services (f) Basic services shall at a minimum include: (1) Care & supervision as defined in Section 87101(c)(3) & Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by:
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During LPA's visit, LPA observed there were no staff members present to provide care and assistance to the residents, which is a potential personal rights risk to residents in care
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This is a zero tolerance violation therefore civil penalty in the amount of $500 has been issued.
Type B
11/10/2022
Section Cited

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87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
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Based on record review the licensee did not comply with the section cited above by not maintaining complete facility files for three out of the four residents which poses a potential health, safety or personal rights risk to persons in care.
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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: 11/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 11/08/2022 09:22 AM - 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: 11/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/10/2022
Section Cited

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87468.2(a)(4) &5 Personal Rights: In addition to the rights listed in Section 87468.1…residents…shall have all of the following personal rights: To care, supervision, & services that meet their individual needs.. delivered by staff that are sufficient in numbers, … and to be served food of the quality and quantity….
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These requirements are not met as evidenced by: During LPA's visit 2:30 PM until 10:30 PM, LPA observed there were no staff present to provide care & assistance to the residents; staff were not available to prepare the meals. R4 walked to KFC to purchase his dinner; R3 went to a supermarket to purchase food, R1 prepared frozen food for R1 & R2 which poses an immediate personal rights risk to the residents in care.
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Absence of supervision is a serious violation as stated in H&S Code 1569.49 (c )(3), an immediate civil penalty of $500 is issued for 11/3/2022. The department may impose $100 of continued civil penalty for each day after the citation is issued until it is corrected.
Type A
11/10/2022
Section Cited

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87413a)(1) Personnel-Operations: In each facility, when regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks.
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This requirement is not met as evidenced by: During LPA's visit between 2:30 PM to 10:30 PM, the administrator who was also acting as the only caregiver, left the facility and did not find other staff to perform the task as the house manager or caregiver.
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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: 11/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 11/08/2022 09:22 AM - 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: 11/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/10/2022
Section Cited

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87405(h)(1) Administrator - Qualifications and Duties: The administrator shall have the responsibility to:(1) Administer the facility in accordance with these regulations, program and budget.
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This requirement is not met as evidenced by: During LPA's visit at 2:30 PM until 10:30 PM, the Administrator failed to follow regulations to provide staffing, meet the food requirements, ensure cleanliness at the facility & maintain resident records.
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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: 11/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5