197608333-5-7-2024-31-AS-RORN-D5AUU7-20240515155303

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608333
Report Date: 05/01/2024
Date Signed: 05/07/2024 11:42:15 AM

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-20221102144232

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:	DATE:	05/01/2024
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:			TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff speak inappropriately towards a resident while in care.
Facility staff does not maintain a comfortable temperature for residents.
Staff smoking on the premises.

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 at 11:30 am; however, no one answered the door.

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 the staff member (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.

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)

Page: 1 of 3

Control Number 31-AS-20221102144232

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: Staff speak inappropriately towards a resident while in care, it’s being alleged that the Administrator has been speaking inappropriately to the residents by cursing, telling the residents to shut up, and telling the residents they are inconveniencing them.

On 11/02/2022, three (3) of the four (4) residents (R1, R2, R3) stated the Administrator has cursed at them, told them to shut up, and told them they were them. R4 did not want to be interviewed. LPA Spaeth interviewed S1 on 11/03/2022 at 5:00 pm via phone call. S1 confirmed the Administrator had cursed at residents, told the residents to shut up, and told the residents they are inconveniencing them. S1 stated this has been occurring for the last two months. Based upon the residents and the staff member's interviews, the allegation is substantiated.

In regard to the allegation facility staff does not maintain a comfortable temperature for residents, it is alleged that the Administrator will not turn up the heat when residents state they are cold. It is also alleged that the Administrator yelled at S1 when S1 tried to turn up the heat in the facility. R1, R2, and R3 all confirmed that they have been cold for the past month, they have told the Administrator they were cold but the Administrator told them they would not turn up the thermostat and told the residents to put on an additional jacket.

On 11/02/2022 and 11/03/2022, R1, R2, and R3 stated the inside temperature was 61 degrees and the outside temperature was 35 degrees F. S1 confirmed the Administrator yelled at S1 because S1 tried to turn up the thermostat. S1 heard the Administrator tell all the residents and S1 to put on an additional jacket. Based upon the staff and resident interviews, the allegation is substantiated.

In regard to the allegation, staff smoking on the premises, it is alleged that the Administrator is smoking marijuana in the facility office and in the garage. R1, R2, R3 all confirmed this takes place on a daily basis. All three residents stated they have asked the Administrator not to smoke in the office or in the garage. However the Administrator stated to them “not going to happen.” R4 did not want to be interviewed. S1 confirmed this occurred on a daily basis. Based upon the staff and resident interviews, the allegation is substantiated.

LPA is unable to conduct an exit interview due to the facility closure but will attempt to provide facility with a copy of this report.

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-20221102144232

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(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: (2) to be accorded safe, healthful accommodations. 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 relocated 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 did not maintain a comfortable temperature within the facility. The Administrator also smoked marijuana in the facility 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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