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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610075
Report Date: 09/16/2024
Date Signed: 09/16/2024 03:04:37 PM


Document Has Been Signed on 09/16/2024 03:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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:
09/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Stephanie DomingoTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Mariana Agban, Angelica Segovia and Evelin Rios conducted an Annual Required visit for this facility. LPAs arrived at the facility and were granted access by Staff #1 (S1). S1 contacted the administrator designee, Stephanie Domingo. LPA Rios met with the administrator shortly after and explained the reason for the visit. The facility is licensed for a total capacity of six (6) non ambulatory residents of which one may be bedridden. Facility has a hospice waiver for six (6).

At approximately 11:40 a.m. LPAs and staff #2 (S) tour the physical plant of the facility inside and out and the following was observed:

Bedrooms: There are six (6) total bedrooms, for private use. Bedrooms were observed to be properly furnished with appropriate furniture, bedding and sufficient lighting. Auditory alarms were observed on Exit doors and were not functioning properly in four (4) doors; two (2) emergency exit doors in two bedrooms and two (2) sliding glass doors in the living area and bedroom area.

Bathrooms: There are two (2) bathrooms. Bathrooms were properly supplied with toilet paper, paper towels, hand soap, nonskid matts and grab bars. LPA observed night-lights in the hallway leading to the bathrooms. Hot water temperature was measured at 2:45 p.m. and read between 117 and 120 degrees Fahrenheit within regulation.

Common Areas: These included the living rooms and dining area. The common areas were clean and clear of clutter, properly furnished. The dining room table is large enough to sit the capacity of the facility. Seating such as couches where in good repair and sit the capacity of the facility. A fireplace was observed off and secured with a screen. LPA observed two (2) telephones accessible to residents.
(Continued on LIC809-C)
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANTELOPE VALLEY MANOR INCORPORATED
FACILITY NUMBER: 197610075
VISIT DATE: 09/16/2024
NARRATIVE
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Laundry and Staff Rooms: The laundry room is located in the hallway by the residents' rooms and leads to the staff rooms. Laundry room is accessible to residents. Detergents and cleaning supplies were observed locked in the laundry room cabinet. Door from laundry room to staff rooms is maintained locked.

Surrounding Grounds: Entry/exits were free of obstructions. The outdoor patio offers shade and there was furniture appropriate for outdoor use. The outdoor area was free of hazards. There is no bodies of water on property.

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of two day perishable and seven day non-perishable food at the facility; properly stored. Knives and sharps were stored in a locked kitchen cabinet.

There are smoke detectors that are hard wired and interconnected. Administrator tested detectors at 12:21 p.m. and LPA observed detectors properly functioning. LPA observed fire doors. There are two fire extinguishers both observed fully charged. The carbon monoxide detector was not functioning at time of visit.



Resident and Staff Files: At 12:30 p.m. LPAs reviewed resident and staff files. LPAs conducted a file review of four (4) out of four (4) resident records to insure compliance of licensing forms. LPA also conducted a file review of two (2) staff records to insure forms and training are up to date and in compliance with licensing forms.

Medications: At 12:50 p.m. LPA reviewed Medication and Medication Records. LPA observed medications locked in a hallway closet. Medications were reviewed for proper storage and documentation. Facility also uses a Medication Administration Record (MAR).

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, there were deficiencies observed during the visit (refer to LIC809-D). Exit Interview Conducted and a Copy of the Report Issued.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/16/2024 03:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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: 09/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(j)

(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in four (4) auditory alarms on exit doors not functioning properly at time of visit which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
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Administrator agrees to send LPA notification the auditory alarms have been added or repaired via email with a picture of each auditory alarm that identified to be missing or not functioning properly by POC due date 10/04/2024.
Type B
Section Cited
CCR
87211(a)(1)(A)
a.Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in three (3) residents identified by left over medication to have been deceased. Administrator could not provide date of death and admitted to submitting death reports which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
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Administrator agreed to submit death reports for the three (3) residents and destroy left over medication of those three residents. Administrator will submit death report via email to LPA by POC due date 10/04/2024.
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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 09/16/2024 03:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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: 09/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in not having at least one (1) functional carbon monoxide detector which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/17/2024
Plan of Correction
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Administrator agrees to purchase new carbon monoxide detector and send picture to LPA via email by POC due date 09/17/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4