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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610075
Report Date: 09/23/2022
Date Signed: 09/23/2022 10:26:44 AM


Document Has Been Signed on 09/23/2022 10:26 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: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: 4DATE:
09/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Stephanie Domingo - designeeTIME COMPLETED:
10:35 AM
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On 9/23/22 at 9:45 a.m. Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA was greeted by staff. LPA observed covid-19 signage, hand sanitizer, PPE supplies, thermometer and a visitor sign in log. LPA reminded staff to conduct infection control protocols for every visitor. LPA explained to the Administrator the purpose of the visit and an entrance interview was conducted.

LPA initiated a physical plant tour at 10:00 a.m. Facility is a Residential Care Facility for the Elderly which was licensed for six (6) non-ambulatory, of which one (1) may be bedridden. Facility has been approved for a hospice waiver for three (3). LPA was able to tour the home and did not observe any immediate health and safety concerns. Sufficient PPE supplies were observed. The fire extinguisher was observed in the kitchen area and has a date of purchase of 9/23/2022. Smoke detectors and carbon monoxide monitors were observed to be functional. Facility maintains a comfortable temperature of 70 degrees Fahrenheit. LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Sharps, cleaning supplies and medications are centrally stored and are kept locked in various kitchen cabinets and drawers. Bedrooms are appropriately furnished and have appropriate lighting. Bathrooms have soap, paper towels and hand washing signs were observed. Extra towels and linens were readily available. There is a clean covered shaded area in the back yard and there are no bodies of water.

No deficiencies issued during today’s visit. Report was signed and delivered by designee and an exit interview was conducted.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2022
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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