197608333-3-11-2022-31-AS-EMIR-CHCTZW-20220816151101

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608333
Report Date: 03/11/2022
Date Signed: 03/11/2022 04:58:04 PM

Unsubstantiated

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
03/11/2022 and conducted by Evaluator Michael Cava

COMPLAINT CONTROL NUMBER: 31-AS-20220311094709

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: 4	DATE:	03/11/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:			TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Lack of care and supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Cava conducted a 10 day complaint visit to the facility to investigate the above allegation. It was reported that facility administrator, was placed on a 72 hour hold. It was also reported that there were firearms present at the facility, but were taken by law enforcement. The investigation consisted of interviews with residents and staff, a physical plant inspection, and record review.

LPA met and interviewed the administrator, Sean Mendoza, and advised him of the allegation. Per interview, the administrator confirms that he was placed on hold for an emotional breakdown over a domestic dispute. Administrator also confirmed that he had some firearms, but he surrendered the firearms to law and forecement. Administrator stated he has two staff scheduled to provide care and supervision. He also lives at the home to provide assistance with care. Interviews with the residents reveal no complaints or concerns with the care and supervision provided to them. Facility staff are able to meet their needs. In regards to food service, residents expressed no complaints.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

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-20220311094709

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
	VISIT DATE: 03/11/2022

NARRATIVE

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LPA also conducted a tour of the physical plant to insure the health and safety of the residents in care and that there is sufficient perishable and non-perishable food. LPA observed two staff present and on duty, providing elements of care and supervision. All four residents were observed in the home, having breakfast and watching television.

Per inspection of the physical plant, there was no immediate health and safety issue present during the visit. There also was no firearms in the possession of the administrator during the visit. LPA observed adequate supervision for the residents in care and enough perishable and non-perishable food. Furthermore, Mr. Mendoza is continuing to oversee the facility operation.

Based on the information obtained, there is not enough evidence to corroborate the allegation of lack of care and supervision. Therefore, the allegation is deemed Unsubstantiated at this time. Mr. Mendoza was advised and a copy of this report will be given.

**LPA was experiencing equipment issues at the time of the visit. Please see hard copy of this report for signature.**

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

LIC9099 (FAS) - (06/04)

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