<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608333
Report Date: 11/07/2022
Date Signed: 02/08/2023 01:41:47 PM


Document Has Been Signed on 02/08/2023 01:41 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: 0DATE:
11/07/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:No staff availableTIME COMPLETED:
01:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At 11:30 a.m. on 11/07/2022 Licensing Program Analysts (LPAs) Nicholas Reed and Wendell Smith conducted an unannounced case management. LPAs knocked on the door and rang the doorbell. LPAs observed dogs in the front yard but no residents or staff at the facility. LPA Reed attempted to call the licensee at 10:10 a.m. and 11:47 a.m. and received no answer. LPA Reed left a voicemail for the licensee.

Since there is no one available at the facility to sign the report, a copy of the report will be sent via certified mail to the Administrator. Administrator will be instructed to sign the report and to forward the signed copy to CCL address at 21731 Ventura Boulevard, Suite 250, Woodland Hills, Ca 91364. An unsigned copy of the report was also printed and left at the facility.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022
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 1