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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197608333
Report Date:
07/12/2022
Date Signed:
07/12/2022 11:33:04 AM
Document Has Been Signed on
07/12/2022 11:33 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 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:
5
DATE:
07/12/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
09:30 AM
MET WITH:
Sean Mendoza
TIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced case management visit to this facility to check on the safety and wellness of the facility. LPA spoke with the administrator and explained the reason for this visit.
LPA conducted a physical plant walk through to ensure no immediate health and safety issues from 9:30-10am. No immediate health and safety issues were noted. LPA also spoke briefly with residents during this visit. LPA interviewed the administrator from 10-11am regarding plans of operations of the facility and staffing. LPA obtained copy of a staff schedule for filing purposes.
No further action is necessary at this time. Exit Interview conducted. Copy of report issued.
SUPERVISOR'S NAME:
Cassandra Harris
TELEPHONE:
(818) 596-4342
LICENSING EVALUATOR NAME:
Wendell Smith
TELEPHONE:
(818) 738-4525
LICENSING EVALUATOR SIGNATURE:
DATE:
07/12/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/12/2022
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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