Antelope Valley Manor

Type of visit: Required - 1 Year

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 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.the state’s words, verbatim · CDSS document, Oct 1, 2025

Type of visit: Required - 1 Year

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) 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.the state’s words, verbatim · CDSS document, Sep 16, 2024