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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608333
Report Date: 06/09/2022
Date Signed: 06/09/2022 01:37:19 PM


Document Has Been Signed on 06/09/2022 01:37 PM - 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: 5DATE:
06/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Courtney RobedeauxTIME COMPLETED:
12:00 PM
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LPA Spaeth conducted an unannounced visit and was greeted by caregiver (S1). Upon entering the facility, LPA signed in, temperature was taken and LPA answered the COVID questions. LPA observed the sign in station which contained a sign in sheet, hand held temperature recorder, additional masks, and hand sanitizer. LPA observed staff member was wearing a mask. LPA was then escorted to the facility office.

LPA Spaeth toured the facility from 10:00 am until 10:25 am with S1. LPA observed a resident was in the living room watching television and LPA observed there was adequate seating in the room. LPA observed the cleaning supplies were locked under the kitchen sink. The kitchen sink area contained paper towels, trash can, and hand soap. LPA observed a four day supply of fresh vegetables and fruits within the refrigerator. All food items such as leftover food was properly covered. The freezer section contained frozen meats. The kitchen also contained a seven day supply of canned goods, pasta, and rice. LPA observed all medications and knives were safely locked in a kitchen cabinet.

LPA observed both bathrooms contained hand soap, paper towels and trash cans. LPA was greeted by a resident who opened bedroom door as LPA and S1 passed by. Resident stated moved in two weeks ago and stated facility staff have been very helpful. LPA observed the resident's room contained bed, linens, night stand and a lamp. LPA also spoke to two residents who stated staff have provided for all their needs.

There are no deficiencies to report at this time. Exit interview conducted, and a copy of the signed report was given to the caregiver.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022
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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