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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610772
Report Date: 08/05/2025
Date Signed: 08/05/2025 02:38:48 PM

Document Has Been Signed on 08/05/2025 02:38 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:2044 WEST CARE MANOR LLCFACILITY NUMBER:
197610772
ADMINISTRATOR/
DIRECTOR:		ANTONA, MARIANFACILITY TYPE:
740
ADDRESS:2044 W AVENUE H6TELEPHONE:
(661) 729-5324
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: 4DATE:
08/05/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:33 AM
MET WITH:Marian Antona - administratorTIME VISIT/
INSPECTION COMPLETED:
02:53 PM
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Licensing Program Analyst (LPA) Evelin Rios conducted a Pre-Licensing Inspection with the applicant/administrator, Marian Antona. An Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on 01/07/2025. This is a change in ownership (CHOW) application. The current census for active license is three (3). All three (3) residents and their responsible party have been notified of CHOW. A fire clearance was approved on 04/04/2025 for five (5) non-ambulatory residents and one (1) bedridden resident, for a total capacity of six (6). At entrance LPA observed required postings by the front door and a sign in folder for visitors..

A tour of the physical plant was initiated at approximately 11:45 a.m., and the following was observed:

KITCHEN: The kitchen is equipped with a refrigerator, stove/oven, dishwasher and microwave. The facility has a sufficient amount of two day perishable and seven day non perishable supply of food. The facility has dishware and cook ware for the capacity of the facility. Knives are kept locked in a kitchen drawer. Cleaning supplies are kept locked in bottom cabinets by the dining area.

BEDROOMS: There are six (06) total bedrooms. Five (05) bedrooms are designated for residents use. Bedroom labeled #5 is for staff only. Per STD 850, rooms #3 is cleared for one (01) bedridden resident. Bedrooms designated for resident use have appropriate furniture with sufficient lighting and storage space.

The smoke alarms and carbon monoxide detector are dual, hard wired and inter-connected. Administrator tested detectors at 11:59 a.m, and they were observed working properly. The facility has one (01) fire extinguisher located by the dining area with purchase date 11/25/2024. (Continue to LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2025
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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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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: 2044 WEST CARE MANOR LLC
FACILITY NUMBER: 197610772
VISIT DATE: 08/05/2025
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Backyard: There is sufficient space for outdoor activities and appropriate outdoor furniture. There are no bodies of water. There are two (02) sheds that are maintained locked. Entrance/exits are clear of obstruction. The facility is completely fenced.

BATHROOMS: The facility has three (03) bathrooms. Two (02) bathrooms are designated for resident use and one (01) is located in a shared bedroom for private use. Bathrooms were observed to have proper fixtures, grab bars, and non-skid mats. The hot water temperature was measured at 115 degrees Fahrenheit.

Common Areas: Furniture such as the dining table, chairs and couches were observed in good repair. Both living room and dining room have sufficient space and lighting. No tripping hazards observed. Passageway to exits are free of obstructions.

Garage: The garage is attached to the building. Entrance to the garage is through the laundry room that is maintained locked. Laundry detergent is kept in the locked laundry room. The laundry room is equipped with a washer and dryer. In the garage LPA observed a deep freezer and facility supplies such as, cleaning supplies and emergency water.

Resident/Staff Records: Facility records, centrally stored medication and medication records are kept in a locked cabinet in the living area. At approximately 12:53 p.m., LPA reviewed three (03) out of three (03) resident records and three (03) staff records.

Component III was held with applicant/administrator, Marian Antona. Pre-Licensing is complete and no deficiencies were observed. This report will be sent to Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when the license has been approved.

Exit interview was conducted. A copy of this report was signed and provided.
NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
LIC809 (FAS) - (06/04)
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