197608333-10-13-2023-31-AS-TAGD-CWXSAN-20231025134237

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608333
Report Date: 10/13/2023
Date Signed: 10/13/2023 01:23:08 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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 VALLEY		FACILITY NUMBER:	197608333
ADMINISTRATOR:	SEAN MENDOZA		FACILITY TYPE:	740
ADDRESS:	45550 11TH ST., W.		TELEPHONE:	(661) 951-2085
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY:	0	CENSUS: 3	DATE:	10/13/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Sean Mendoza		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Neglect/Lack of Care and Supervision

INVESTIGATION FINDINGS:

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This is an amended copy of the report previously issued on 10/12/2022. This report supersedes the report previously issued. The findings for this complaint has been updated.

Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced subsequent complaint investigation for the allegation(s) listed above.

The investigation consisted of the following: On 9/16/2022, LPA Spaeth conducted a 10-day visit, toured the physical plant and requested the staff roster. LPA conducted interviews.

Regarding the allegation: Neglect/Lack of Care and Supervision. It’s being alleged that R1 is being neglected and has bed sores on their bottom. LPA Spaeth interviewed S1 who stated on 9/19/2022 and 9/20/2022 they reported to the facility at 8:00 am and found R1 was in a soaked bed with no sheets. R1 was dressed in only a t-shirt, laying on a small pad and had no diaper on their body. S1 stated the

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MANOR HOUSE OF ANTELOPE VALLEY	FACILITY NUMBER: 197608333
	VISIT DATE: 10/13/2023

NARRATIVE

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Administrator was the staff member who worked the night shift on 9/18/2022 and 9/19/2022. LPA Spaeth attempted to interview R2 but was unable to do so. R3 refused. LPA attempted to interview the Administrator, but the Administrator refused.

LPA Spaeth was unable to obtain medical documentation regarding R1’s alleged bed sores. Based on LPA’s investigation the allegation is unsubstantiated.

Exit interview conducted, and a copy of the report was mailed to the Licensee.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

LIC9099 (FAS) - (06/04)

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