197610900-4-23-2026-31-AS-RCOR-DTES43-20260423133205

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610900
Report Date: 04/23/2026
Date Signed: 04/23/2026 01:32:30 PM

Document Has Been Signed on 04/23/2026 01:32 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ANTELOPE VALLEY ASSISTED LIVING LLC		FACILITY NUMBER:	197610900
ADMINISTRATOR/ DIRECTOR:	MORALES, AMY M		FACILITY TYPE:	740
ADDRESS:	40238 PEONZA LANE		TELEPHONE:	(661) 992-3245
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY: 6		CENSUS: 0	DATE:	04/23/2026
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:35 AM
MET WITH:	Amy Morales-Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On Thursday, 4/23/26, Licensing Program Analyst (LPA) Ray Comer conducted an announced pre-Licensing visit and met with Administrator, Amy Morales. Licensee is " ANTELOPE VALLEY ASSISTED LIVING LLC". Fire Clearance granted on 9/30/25 for five (5) non-ambulatory residents, and one (1) resident which may be bedridden in Room #5. Hospice waiver approved for four (4) residents. Purpose of today’s visit was to inspect to ensure that the facility is in compliance with the rules and regulations of California Code of Regulations, Title 22, Division 6. Facility is a single-story home, with a total of five (5) bedrooms; one (1) shared, three (3) private, and one (1) for staff-only use. Facility has two (2) bathrooms. LPA tour of the physical plant was initiated at approximately 10:45 am, and observed the following: KITCHEN - LPA observed kitchen appliances, (Refrigerator, stove, microwave, etc.) working properly. Knives and sharps were stored in a lower cabinet, secured by locking magnetic fob, and inaccessible to residents. Cleaning agents were stored in secured lower cabinet underneath the large sink and inaccessible to residents. FIRE SAFETY: Multiple dual smoke/carbon monoxide detectors are installed, hardwired, and interconnected throughout the facility. Smoke detectors were tested and were working properly. One (1) Fire extinguisher was observed in the living room area; fully charged with purchased date of 9/19/2025. Evacuation routes were clearly labelled and posted. All entry\exit doors signal an auditory alert when opened. [LIC 809C]- Continued

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Raymond Comer
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/23/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2026

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANTELOPE VALLEY ASSISTED LIVING LLC	FACILITY NUMBER: 197610900
	VISIT DATE: 04/23/2026

NARRATIVE

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MEDICATIONS- Mediations will be stored in kitchen area cabinet, secured by a locking magnetic fob and inaccessible to residents. First aid kit was observed as fully stocked with required supplies.

BEDROOMS – All bedrooms have sufficient lighting, and contained bed, linens, nightstand, chest of drawers, chair, trash can with a lid, and closet space.

BATHROOMS- All bathrooms contained hand soap, slip resistant floor mats, grab bars and a trash can. Water temperature was measured at 105.0 degrees F; within the required temperature range.

LAUNDRY – Laundry room is located across from bedroom# 5. Detergents and other cleaning agents were secured by locking magnetic fob in laundry room cabinets. Multiple closets were observed in the facility containing fresh linens, blankets, and towels for residents use.

COMMONS: Consisting of the living room, and the dining area. Both Living room and Dining room were furnished with chairs and large table, television, and a sofa with seating adequate for residents. There were no hazards observed. There is a working telephone line, and internet access.

OUTDOORS- Backyard area has a shaded area with a table and chairs sufficient for residents and staff. The driveway, passageways and entrance to the home were clear of obstruction.

GARAGE: Garage is attached and accessible, via a hallway door near bedroom#5. LPA observed service door to garage as key-locked.

RECORDS- Staff and resident records will be stored in locked file cabinet located in the office area, (Room#1) adjacent to the living room.

Component III was conducted with the applicant from 12:30 pm to 1:15 pm.

[LIC 809C] Continued

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Raymond Comer
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/23/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2026

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANTELOPE VALLEY ASSISTED LIVING LLC	FACILITY NUMBER: 197610900
	VISIT DATE: 04/23/2026

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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. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview was conducted and a copy was provided to Administrator.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Raymond Comer
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/23/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2026

LIC809 (FAS) - (06/04)

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