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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610075
Report Date: 04/17/2026
Date Signed: 04/17/2026 01:56:16 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
04/13/2026 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20260413220217
FACILITY NAME:ANTELOPE VALLEY MANOR INCORPORATEDFACILITY NUMBER:
197610075
ADMINISTRATOR:RICHARD GARCIAFACILITY TYPE:
740
ADDRESS:2801 HUSTON PLACETELEPHONE:
(818) 332-6150
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 5DATE:
04/17/2026
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Richard Garcia - AdministratorTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Resident sustained abrasion due to staff neglect.
Staff was not available to provide access to the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Evelin Rios and Licensing Program Manager (LPM) conducted an unannounced complaint visit to investigate the above allegations. LPA and LPM arrived to the facility and met with the Administrator, Richard Garcia and explained the reason for the visit. An entrance interview was conducted.
The investigation consisted of the following: At 8:50 AM, LPA initiated a physical plant tour of the facility to ensure the health and safety of the residents in care. From approximately 9 AM to 10:30 AM, LPA and LPM interviewed three (3) out of five (5) residents. One resident was unable to answer questions, and another was out in the community. LPA and LPM also interviewed the staff member who was present during the incident in question, as well as the administrator. At 11:00 AM, LPA reviewed and obtained copies of the following documents: an unusual incident report for 04/13/2026, Residents’ Physician’s Reports, Resident Appraisals, Functional Capabilities Assessments, and discharge instructions for Resident #1(R1). At 12:30 PM the resident that was out in the community arrived to the facility and was interviewed by LPA and LPM.
(Continue to LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 31-AS-20260413220217
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANTELOPE VALLEY MANOR INCORPORATED
FACILITY NUMBER: 197610075
VISIT DATE: 04/17/2026
NARRATIVE
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(Continued from LIC-9099)

The investigation revealed:

Allegation: Resident sustained an abrasion due to staff neglect and staff was not available to provide access to the facility. It is alleged that on 04/13/2026, Resident #1 (R1) slid off their bed resulting in R1 sustaining an abrasion and staff was not available to provide access to paramedics. Interview with the administrator and staff revealed that on 04/13/2026, R1 was agitated until around 12:30 AM, once he was calm and sleeping the staff went to bed. Then around 5AM, the staff was woken up by paramedics that had gained access through a resident’s bedroom window. Interview with staff present on the day in question revealed they did not hear R1’s calls for help or paramedics ringing the doorbell. Staff present on the day in question stated they had been tired due to R1’s agitated state and did not hear the paramedics ring the bell. According to the Unusual Incident Report provided by the facility to LPA Rios, paramedics informed staff that the resident had been calling for help, and when no one answered another resident dialed 911. LPA’s review of R1’s Physician’s Report, dated 12/31/2025 notes R1 has dementia. Interviews with two (2) of the four (4) residents confirmed that paramedics responded and/or entered the facility through the window due to an emergency call at the facility involving a resident.

Based on interviews and record reviews the allegation Resident sustained an abrasion due to staff neglect and staff was not available to provide access to the facility are deemed Substantiated at this time.

California Code of Regulations, Title 22, Division 6, Chapter 8 is cited on the attached LIC9099-D.



Exit interview conducted. Appeal Rights and copy of this report provided to the administrator.
SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20260413220217
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANTELOPE VALLEY MANOR INCORPORATED
FACILITY NUMBER: 197610075
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/18/2026
Section Cited
CCR
87705(b)(2)
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(b) Licensees shall be responsible for the following: (2)... ensuring there is at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal, or observation, to require awake night supervision.
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Administrator will create a plan to ensure supervision is conducted at night and staff receive proper training. Plan will be submitted to the department by POC due date 04/18/2026.
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This requirement is not met as evidenced by: Based on LPAs interviews, R1 was observed agitated in the early hours of the morning and staff present went to sleep which poses an immediate health and safety or personal rights risk to clients in care.
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Type A
04/18/2026
Section Cited
CCR
87411(a)
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Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...This requirement is not met as evidenced by:
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Administrator will conduct in-service staff training regarding responding to emergencies and will submit training information and staff signature log to the department by POC due date 04/18/2026.
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Based on LPAs interviews, staff present was not available to provide access to paramedics when they arrived to the facility which poses an immediate health and safety or personal rights risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Mary G Flores
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
04/13/2026 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20260413220217

FACILITY NAME:ANTELOPE VALLEY MANOR INCORPORATEDFACILITY NUMBER:
197610075
ADMINISTRATOR:RICHARD GARCIAFACILITY TYPE:
740
ADDRESS:2801 HUSTON PLACETELEPHONE:
(818) 332-6150
CITY:LANCASTERSTATE:CAZIP CODE:
93536
CAPACITY:6CENSUS: 5DATE:
04/17/2026
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Richard Garcia - Administrator TIME COMPLETED:
02:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not respond to a resident's call for care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPA) Evelin Rios and Licensing Program Manager (LPM) conducted an unannounced complaint visit to investigate the above allegations. LPA and LPM arrived to the facility and met with the Administrator, Richard Garcia and explained the reason for the visit. An entrance interview was conducted.
The investigation consisted of the following: At 8:50 AM, LPA initiated a physical plant tour of the facility to ensure the health and safety of the residents in care. From approximately 9 AM to 10:30 AM, LPA and LPM interviewed three (3) out of five (5) residents. One resident was unable to answer questions, and another was out in the community. LPA and LPM also interviewed the staff member who was present during the incident in question, as well as the administrator. At 11:00 AM, LPA reviewed and obtained copies of the following documents: an unusual incident report for 04/13/2026, Residents’ Physician’s Reports, Resident Appraisals, Functional Capabilities Assessments, and discharge instructions for Resident #1(R1). At 12:30 PM the resident that was out in the community arrived to the facility and was interviewed by LPA and LPM.
(Continue to LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20260413220217
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANTELOPE VALLEY MANOR INCORPORATED
FACILITY NUMBER: 197610075
VISIT DATE: 04/17/2026
NARRATIVE
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The investigation revealed:

Allegation: Staff did not respond to a resident's call for care. It is alleged that on 04/13/2026, Resident #1 (R1) slid off their bed and staff did not respond to R1's call for assistance. Based on staff interviews, around 5AM, the staff was woken up by paramedics that had gained access through a resident’s bedroom window. Interview with staff present on the day in question revealed they did not hear R1’s calls for help. Interview with the administrator revealed R1 has a call button near them. Interview with R1 revealed they did not push the call button on the day in question. Interview with Resident #2 (R2) revealed they called 911 as R1 had appeared at their door asking them to call 911 and did not hear R1 calling for help prior to R1 entering their room. According to the Unusual Incident Report provided by the facility to LPA Rios, paramedics informed staff that the resident had been calling for help, and when no one answered another resident dialed 911. Interviews with four (4) of the four (4) residents interviewed stated staff assist them when they call for assistance. Two (2) of the interviewed residents stated they didn't hear anyone calling out for help. Although R1 was not assisted on 4/13/26 by staff it is unknown if R1 called for assistance and the amount of time R1 was in need of assistance. Therefore the allegation is unsubstantiated.

Based on interviews the allegation, staff did not respond to a resident's call for care is deemed Unsubstantiated at this time.


Exit interview conducted. Copy of report provided to the administrator.
SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5