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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608333
Report Date: 05/31/2022
Date Signed: 05/31/2022 11:27:46 AM


Document Has Been Signed on 05/31/2022 11:27 AM - 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: 3DATE:
05/31/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sean MendozaTIME COMPLETED:
11:00 AM
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An Informal Conference was conducted today in the Woodland Hills Adult and Senior Care Regional Office. The purpose of this Informal Conference is to discuss the incident that occurred on March 28, 2022, Administrator left the facility for a few hours but there were no caregivers present to assist residents with daily needs.

Present at today's meeting are the following:
· Sean Mendoza - Administrator
· Cassandra Harris, Licensing Program Manager (LPM)
· Melissa Spaeth, Licensing Program Analyst (LPA)


The informal conference process was explained to the Licensee. The Licensee was also informed that this Informal Conference is a part of the administrative action process. Further citations may result in a Non-Compliance Conference, which could lead to a referral to the Department's Legal Division for possible license revocation or other administrative actions.
BRIEF HISTORY: Facility has been in operation since licensure on November 13, 2012 for a maximum of six (6) residents. LPM Harris discussed and expressed concerns regarding the March 28, 2022 incident.

Administrator agreed to provide a new LIC 500 and include new staff on the schedule, updated facility sketch to indicate staff room, resident occupancy and ambulatory status. Administrator will provide a copy of proof of new staff submitted record clearance.

The Licensee was informed that Community Care Licensing (CCL) shall continue to frequently monitor the facility as often as necessary to ensure the Licensee's compliance with Title 22 Regulations.

Exit interview conducted, Appeal Rights discussed, and a copy of the report was issued to the Caregiver.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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