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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610075
Report Date: 09/14/2020
Date Signed: 09/14/2020 11:35:17 AM

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:ANTELOPE VALLEY MANOR INCORPORATEDFACILITY NUMBER:
197610075
ADMINISTRATOR:VIRAY, JEROMEFACILITY TYPE:
740
ADDRESS:2801 HUSTON PLACETELEPHONE:
(818) 332-6150
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 6DATE:
09/14/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Jerome Viray/ AdministratorTIME COMPLETED:
11:45 AM
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Due to the Covid -19 pandemic, this pre-licensing was conducted via video phone. No digital signature was attained and a copy of the report was emailed to the administrator. A "wet" signature is on file in the main facility folder.
Component III was also conducted on todays visit.

A pre licensing visit was conducted by Licensing Program Analyst (LPA), Patrick Shanahan. The LPA met with administrator, Jerome Viray. This is a change of ownership application.

LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. First-aid kit is complete; facility has adequate linen, perishable and nonperishable food supplies. Hot water measured at 119 degrees Fahrenheit. There is no swimming pool or other body of water present. Facility has working alarms on all exits. The backyard is completely fenced and gated with self-latching mechanisms. There is patio area backyard with table and chairs for resident use. All chemicals and sharps are in locked cabinets and drawers. Facility has 2 bathrooms. Fire Clearance is approved for 3 bedridden and 3 non ambulatory residents. There are 6 single rooms and no staff room. The washer and dryer are located in a hallway next to the garage.

Facility is in compliance with Title 22 Regulations at this time. This report will be sent to the Centralized Application Unit (CAU). You will be notified by the CAU Analyst when your license has been approved.
You are not allowed to begin operating until you have been notified that your license has been approved by the CAU Analyst. Failure to comply could affect approval of your license.
Exit interview held and report issued.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2020
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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