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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610709
Report Date: 04/28/2025
Date Signed: 04/28/2025 12:31:42 PM

Document Has Been Signed on 04/28/2025 12:31 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:ASHTON HOME LLCFACILITY NUMBER:
197610709
ADMINISTRATOR/
DIRECTOR:		ZHOU, PHILIPFACILITY TYPE:
740
ADDRESS:3322 ASHTON PLACETELEPHONE:
(818) 689-4358
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: 4DATE:
04/28/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Zhou, Phil - Administrator and Kazeem Abass
TIME VISIT/
INSPECTION COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Evelin Rios conducted a Pre-Licensing Inspection with the applicant representative / administrator, Phil Zhou and administrator designee Kazeem Abass. The applicant is"ASHTON HOME LLC". This is a Change in Ownership "CHOW" application. A fire clearance was approved on 10/23/24 for six (6) non-ambulatory residents, one (1) of which may be bedridden in Room #3. The facility has a total of six (6) bedrooms and three (3) bathrooms.

A tour of the physical plant was initiated at approximately 9:15 AM and the following was observed:

KITCHEN: The facility has a Kitchen that is equipped with a refrigerator, microwave, stove, dishwasher and sink. There was an adequate supply of perishable and nonperishable food. Knives were observed locked in a kitchen cabinet. Cleaning supplies and other toxins were observed locked under the kitchen sink cabinet.

BEDROOMS: There are five (5) bedrooms designated for residents use; four (4) private and one (1) shared. The bedrooms are furnished with beds, night stand, chairs, dressers, bedding and appropriate linens. The bedrooms have sufficient lighting and storage.

BATHROOMS: The facility has three (3) bathrooms; one (1) is located in the shared bedroom. The bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water temperature was measured at 118.4°F, within regulation.

LAUNDRY ROOM: The laundry room leads to the garage and is maintained locked. Laundry detergents and other cleaning agents were locked in a cabinets inside the laundry room. The garage was observed to be locked during visit. The facility keeps a second refrigerator and a freezer. (Continued on LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2025
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 3
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: ASHTON HOME LLC
FACILITY NUMBER: 197610709
VISIT DATE: 04/28/2025
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(continued from LIC 809)
COMMON AREAS: These included the living room and the dining area. Living room was furnished with chairs and side tables. The living room area was furnished with a television, recliners and chairs that sit the capacity of the facility. There were no visible immediate hazards. There is a working telephone line and internet accessible to residents. Dual smoke/carbon monoxide alarms were tested at 10:15 AM and observed to be operational. Fire extinguisher was observed fully charged with service date of 01/09/25.

MEDICATIONS: The medication cabinet is located in the kitchen and has a locking mechanism. Two first aid kits with manual were observed inside a hallway cabinet. LPA reviewed centrally stored medication records.

Staff/Resident Records: Staff and resident records are kept locked in a filing cabinet. LPA reviewed resident and staff records for compliance.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. All entry and exit doors have a functional auditory alarms when the doors open. The backyard of the facility has two covered patios and backyard furniture to accommodate the residents. There are no bodies of water.

Component III was conducted with the Administrator /Licensee Representative and Administrator designee. No deficiencies were observed during visit.

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 conducted. Copy of this report issued.

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025
LIC809 (FAS) - (06/04)
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