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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610075
Report Date: 08/31/2021
Date Signed: 08/31/2021 12:06:09 PM

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: 5DATE:
08/31/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Stephanie Domingo/ StaffTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Shanahan conducted an unannounced annual required visit on this day. LPA was greeted by staff and given a tour of the facility at 10:10 am with Staff Stephanie Domingo. The facility is a single-story home consisting of a living room, dining room, kitchen, office, 6 client bedrooms, 4 staff bedroom, 2 bathrooms, laundry room. There is a backyard and patio area which wraps around and exits on both sides of the house. The LPA's temperature was taken upon entry and all staff were observed to be wearing masks.

LPA inspected the clients' rooms, observing them to be clean and appropriately furnished. Bathrooms were sanitary and contained working fixtures. Hot water temperature measured between 105- and 120-degrees Fahrenheit. The kitchen was clean, containing working appliances and an adequate supply of perishable and non-perishable foods. Knives, cleaning supplies and other potentially hazardous items were secured and inaccessible. Common areas were clean and appropriately furnished as was the outdoor patio area. . LPA observed the fire extinguishers to be charged, emergency disaster plan posted, and smoke/ carbon monoxide detectors functional.

The facility is following their approved mitigation plan at this time.

Report reviewed, signed, and delivered. Exit interview conducted, no deficiencies cited.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
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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