197608333-4-1-2022-31-AS-CHAS-CEGMP9-20220516094647

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608333
Report Date: 04/01/2022
Date Signed: 04/01/2022 03:50:03 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
03/29/2022 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20220329104320

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:	6	CENSUS: 3	DATE:	04/01/2022
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Sean Mendoza		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Lack of Care and Supervision for the residents

INVESTIGATION FINDINGS:

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LPA Spaeth arrived at the facility was greeted by Sean Mendoza. LPA Spaeth stated the purpose of the visit was to present findings regarding the allegation, lack of care and supervision for the residents. Upon entering the facility, LPA observed the COVID signs on the door, LPA's temperature was recorded, and LPA signed in at the sign in station.

On March 29, 2022, LPA interviewed all three residents who confirmed Administrator left the facility on March 28, 2022 for a few hours but there were no caregivers present to assist residents with daily needs. LPA also spoke to the two caregivers who work for the facility and both caregivers confirmed did not work on Sunday, March 27, 2022. On March 29, 2022, LPA interviewed Administrator who stated did not leave the facility. Based upon LPA's interview with the residents and caregivers, this allegation is substantiated. Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency was cited (refer to LIC 809-D).
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 Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022

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-20220329104320

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: 04/01/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/05/2022 Section Cited HSC 1548(b)(3)	1 2 3 4 5 6 7	1458(b) (b) The department shall assess an immediate civil penalty of five hundred dollars .. per violation and...($100) for each day the violation continues after citation for any of the following serious violations: (3) Absence of supervision, as required by statute or regulation. This requirement was not	1 2 3 4 5 6 7	Licensee will submit LIC 500 to LPA
	8 9 10 11 12 13 14	met as evidenced by: Based upon LPA's interviews of the residents, Administrator left the facility & there were no staff members present within the facility. Licensee failed to ensure staff coverages which poses an immediate health and safety rights to residents in care.	8 9 10 11 12 13 14	Because this violation resulted in residents along at the facility without caregivers present, an immedaite civil penalty in the amount of $500 is issued.
	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: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022

LIC9099 (FAS) - (06/04)

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