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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 03:59:01 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
09/14/2022 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20220914135841
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: 3DATE:
10/12/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Neglect/Lack of Care and Supervision
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 health or safety issues. LPA conducted interviews of reporting party and staff from TIME.

It was reported that R1 was left in a wet bed without a diaper, and only dressed in a t-shirt on two occasion. Based upon LPA's interview of reporting party and staff, 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: 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-20220914135841
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
87625(a)(1)(D)
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Managed incontinence (a) The licensee shall be permitted to accept or retain a resident who has a..incontinence condition…(1) the condition can be managed with …the following: (D) the use of incontinent care products. This requirement was not met based upon:
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Administrator and LPA reviewed basic services regulation section. Administrator stated will select new residents who do not need assistance with daily living skills such as medicaiton distribution and showering.
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Based upon LPA's interview of the reporting party and staff member, R1 was lying in a bed with no diaper and a wet bed on two occasions which poses an immediate 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: 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)
Page: 2 of 2