197608333-5-6-2024-31-AS-RORN-D5AUAG-20240515152443

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608333
Report Date: 05/01/2024
Date Signed: 05/06/2024 04:28:19 PM

Substantiated

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
11/02/2022 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20221102163625

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: 0	DATE:	05/01/2024
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:			TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Administrator yells at staff in front of residents
Administrator is not providing a safe environment for residents

INVESTIGATION FINDINGS:

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On 5/01/2024 Licensing Program Analyst (LPA) Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth knocked on the door but no one was on the property. LPA sent a certified lettervia mail as of today to the Administrator with the 9099 documents explaining LPA Spaeth completed the investigation.

The investigation consisted of the following: on 11/03/2022, LPA Melissa Spaeth and LPA Nicholas Reed initiated a complaint investigation. LPA Spaeth observed the Administrator and S1 were not present at the facility. The LPAs observed all four residents were alone at the facility. LPA Spaeth interviewed three (3) of the four (4) residents on 5/23/2023 at 3:00 pm until 4:30 pm and interviewed the staff member (S1) at 5:00 pm via phone call. Resident 4 (R4) declinded the interview.

Continued on 9099-C

Substantiated

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: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

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-20221102163625

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: 05/01/2024

NARRATIVE

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The investigation revealed the following…Regarding the allegation: Administrator yells at staff in front of residents. It’s being alleged that on 11/02/2022, the administrator was yelling at the staff member (S1), was verbally aggressive to S1, and was exhibiting angry outbursts. On 11/02/2022, R1, R2, and R3 all witnessed witnessed the Administrator yelling at S1, was verbally aggressive to S1, was throwing items throughout the facility, and asked S1 to leave. R1, R2, and R3 all confirmed they did not feel safe and R1, R2, and R3 locked themselves in their rooms due to fear of the Administrator. R4 did not want to be interviewed.

LPA Spaeth interviewed S1 on 11/03/2022 at 5:00 pm via phone call. S1 confirmed they were working on 11/02/2022. The Administrator screamed and yelled at S1. The Administrator was throwing things throughout the facility. S1 confirmed R1, R2, R3, and R4 were locked in their rooms. S1 confirmed this occurred and the Administrator asked S1 to leave. Based upon interviews conducted, the allegation is substantiated.

Regarding the allegation: Administrator is not providing a safe environment for residents, it’s being alleged that residents do not feel safe living in the facility. R1, R2, and R3 unanimously stated since the Administrator yelled at the residents and has outbursts of anger, the residents do not feel safe. R4 did not want to be interviewed. S1 confirmed that the residents had stated they did not feel safe due to the Administrator’s outburst of angers. Therefore, the allegation is substantiated.

LPA is unable to conduct an exit interview due to the facility closure, LPA Spaeth sent the documents to the Administrator via certified mail.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20221102163625

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/01/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/01/2024 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities... shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents...This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility closed as of 11/03/2022 and residents were located to other facilities. A plan of correction is not required.
	8 9 10 11 12 13 14	Based upon staff and resident interviews, the Administrator failed to treat residents with respect and failed to provide a safe environment which is a potential health risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

LIC9099 (FAS) - (06/04)

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