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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608333
Report Date: 09/12/2022
Date Signed: 09/16/2022 01:47:05 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
09/12/2022 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20220912170014
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:
09/12/2022
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Sean MendozaTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Lack of Care and Supervision for the residents
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 conduct an investigation regarding a complaint which states staff were not not present at the facility. Caregiver stated the Administrator was not at the facility.

LPA conducted a facility tour and did not observe any safety issues. LPA interviewed the reporting party at 2:30 pm until 2:45 pm. LPA interviewed residents at 3:00 pm until 3:30 pm.

Based upon LPA's interview of reporting party and residents, this complaint is substantiated. 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: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022
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-20220912170014
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: 09/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/19/2022
Section Cited
CCR
1548(b)(3)
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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 statute or regulation.
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Administrator will send weekly work schedule of staff members for three weeks.
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This requirement was not met based upon: Based upon LPA's interviews of the complainant and residents, 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 caregivers present, an immediate civil penalty in the amount of $500 is issued.
Type A
09/12/2022
Section Cited
CCR
87761(b)(1)
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87761(d) When a facility is cited for a deficiency & violates the same regulation subsection within 12 month period, the facility shall be cited & an immediate penalty of $150 per cited violation shall be assessed for one day only…This requirement was not met based upon:
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Previous Complaint 31-AS-20220329104320 was substantiated with the same allegation, Lack of Care and Supervision for the residents.
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Because this violation resulted in residents alone at the facility without caregivers present, an immediate civil penalty in the amount of $500 is issued.
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: 09/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2