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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610075
Report Date: 10/01/2025
Date Signed: 10/01/2025 06:36:38 PM

Document Has Been Signed on 10/01/2025 06:36 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ANTELOPE VALLEY MANOR INCORPORATEDFACILITY NUMBER:
197610075
ADMINISTRATOR/
DIRECTOR:		VIRAY, JEROMEFACILITY TYPE:
740
ADDRESS:2801 HUSTON PLACETELEPHONE:
(818) 332-6150
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: 5DATE:
10/01/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Richard Garcia, House Manager TIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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At 2:00pm, Licensing Program Analysts (LPAs) Angela Panushkina and Perchui Milena Khurshudyan arrived at the facility to conduct an annual inspection. LPAs met with the House Manager and explained the reason for the visit.

A tour of the physical plant was initiated at 2:05pm and the following was observed:

The facility is cleared for six (6) Non-Ambulatory of which one (1) may be bedridden in room 3 only. Facility also has a approved hospice waiver for six (6) residents.

Kitchen: The kitchen area is equipped with a refrigerator, microwave oven and sink. LPA observed there to be sufficient stock of perishable and non-perishable foods. Food storage and preparation areas are clean and inaccessible to pests. All knives were observed to be locked in the kitchen cabinet. The fire extinguisher was purchased on 11/15/2024.

Medications: Medications and resident/staff files are kept in locked closet, located in a hallway. There is a complete first-aid kit it with all required supplies and with the first aid manual. LPAs also observed (insulin, and narcotic) medications stored in a small fridge

Bedrooms: The facility has a total of ten (10) bedrooms of which six (6) are designated for residents use. Four (4) bedrooms are for live-in staff. The bedrooms are appropriately furnished with sufficient closet space and have sufficient lighting. All exit doors will have an auditory alarm. LPAs also observed that three (3) out of five (5) residents have 1/2 bed rail, however, upon review of files, no doctors order was available/observed.
Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Angela Panushkina
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANTELOPE VALLEY MANOR INCORPORATED
FACILITY NUMBER: 197610075
VISIT DATE: 10/01/2025
NARRATIVE
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Bathrooms: Facility has three (3) bathrooms. All bathrooms were observed to have nonskid mats. Bathrooms have soap, paper towels and all trash cans have a lid. Extra towels and linens were readily available. The hot water temperature measured at 155.1°F.

Common Areas: The facility maintains a comfortable temperature of 74°F. LPAs observed all common areas are furnished with adequate furniture to accommodate a maximum capacity of six (6) residents. There is a functioning telephone on the premises. Smoke detectors carbon monoxide is located throughout the facility and at 2:30pm they were tested and observed to be operational.

Laundry Room: The laundry is located by the staff room. The washer/dryer appears to be in good condition. Laundry supplies are kept inaccessible when not in use with supervision.

Outside Areas: The back of the facility has sufficient yard space. At 2:40pm, LPAs observed appropriate outdoor furniture, with a covered shaded area for the residents. The outdoor area is free of visible immediate hazards. LPAs discussed the importance of maintaining the care and supervision to meet the needs of residents. There are no bodies of water.

Between 2:45pm to 3:50pm, LPAs reviewed records of five (5) residents and three (3) staff. Resident and staff records appeared to be complete and updated. Resident’s files contain signed admission agreements and a medical assessment, and all other required documentation.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC 809-D.

Exit interview conducted. Appeal rights explained and copy of this report signed and delivered.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Angela Panushkina
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/01/2025 06:36 PM - It Cannot Be Edited


Created By: Angela Panushkina On 10/01/2025 at 04:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs inspection, the licensee did not comply with the section cited above, the licensee did not comply with the section cited above. At 2:20pm, LPAs measured a hot water termperature at 155.1°F. This poses an immediate health, safety risk to persons in care.
POC Due Date: 10/03/2025
Plan of Correction
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Licensee/Administrator agreed to adjust a hot water temperature. Licensee/Administrator will measure a hot water temperature twice a day (8am and 8pm) for seven (7) days and submit the log to LPA on 10/08/25
Type A
Section Cited
CCR
87608(a)(3)
Postural Supports. A written order from a physician indicating the need for postural support shall be maintained in the resident’s record. The licensing agency is authorized to require additional documentation if needed

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation and record review, the licensee did not comply with the section cited above, by not obtaining doctors order for 1/2 bedrails for R2, R3 and R4, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/03/2025
Plan of Correction
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Administrator will follow up with the doctor or family member to ensure a prescription is received and kept in the file for R1, R2 and R3. A copy of the prescription order will be submitted to LPA by POC date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Angela Panushkina
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 10/01/2025 06:36 PM - It Cannot Be Edited


Created By: Angela Panushkina On 10/01/2025 at 04:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(C)(2)
Incidental Medical and Dental Care(h)The following requirements shall apply to medications which are centrally stored(C) Because...dangers related to the medication itself (2)...medicines shall be kept in a safe and locked place that is not accessible to persons other than employees…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation and inspection, the licensee did not comply with the section cited above, by failling to lock norco and insulin medications stored in the small refrigerator located across from bedroom #6, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/03/2025
Plan of Correction
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Administrator will place a lock on the refrigerator or purchase a box with the lock and submit proof of pictures to LPA by POC date.
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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Angela Panushkina
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2025


LIC809 (FAS) - (06/04)
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