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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804288
Report Date: 03/27/2025
Date Signed: 03/27/2025 01:02:19 PM

Document Has Been Signed on 03/27/2025 01:02 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ASHLEY'S CARE HOMESFACILITY NUMBER:
486804288
ADMINISTRATOR/
DIRECTOR:		CHIONG, OMARFACILITY TYPE:
740
ADDRESS:1855 SANTA MONICA STTELEPHONE:
(916) 622-8580
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 0DATE:
03/27/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Omar Chiong-Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:10 PM
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At approximately 9:30 AM, Licensing Program Analysts (LPAs) Julie Florio and Star Stevenson arrived announced to conduct a pre-licensing inspection and was greeted by Licensee/Applicant, Omar Chiong. This pre-licensing inspection is being conducted for an initial licensing of an Residential Care Facility for the Elderly (RCFE). Fire Clearance has been approved for 6 non-ambulatory residents. All bedrooms 1,2,3,4,5 are approved for non-ambulatory use. Facility has a dementia care plan. Licensee/Applicant is not currently in partnership with North Bay Regional Center (NBRC) or a placement agency but plans to look into this.

At approximately 10:00 AM, LPAs initiated a tour of the facility and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperature in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPAs observed resident showers need shower curtain rods and curtains, Applicant agreed to purchase and install these prior at accepting residents into care. Applicant had non-slip mats and grab bars in place. LPAs observed a supply of clean linens, hygiene products, and paper products available for residents. Hallways are equipped with night lights and residents' bedrooms have all the appropriate furnishings as outlined in Title 22 regulations.

LPAs observed dishes and cooking supplies for resident use with sharps and other hazardous items kept secured in various designated drawers and cabinets as well as under the kitchen sink. Cabinets in communal areas of the facility containing cleaning supplies and other items that could pose a risk were observed locked.

Continued on LIC809-C...
NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2025
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ASHLEY'S CARE HOMES
FACILITY NUMBER: 486804288
VISIT DATE: 03/27/2025
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...continued from LIC809...

Applicant agrees to keep magnets and keys to these locked areas in facility safe secured and inaccessible to residents in care. Licensee agrees to maintain at least two days of perishable foods and currently has one week of non-perishable foods and an emergency water supply. The required posters were observed hanging in the facility entryway and licensee purchased a long-term care ombudsman poster during today's visit. Licensee was advised to post a copy of their admissions agreement and emergency disaster plan in common area of the facility. Licensee has suggested visiting hours and how arrangements can be made for alternative visiting hours. The facility currently has Applicant and two staff members associated to facility and will hire an additional staff member once license is approved. Applicant has been informed of association and staff transfer process. LPAs observed a sample menu posted in the common area to indicate a healthy and balanced set of meals for residents in care. The facility has a designated computer area for residents in care and Applicant will provide an ipad for residents to use. Facility phone was tested and operational during inspection.

Facility has a designated locked closet, as well as locked drawer and cabinet for centrally stored medications and resident, staff, and facility files. LPAs observed first aid kit, PPE, other emergency supplies, activity schedule, and games available for resident use. LPAs recommended that Applicant add additional, age appropriate activities for elderly residents. Facility has a fire extinguisher, which was last inspected 10/2024 and is fully charged. Smoke and Carbon Monoxide detectors were tested and operational during inspection.

The backyard features paved walkways and a shaded patio area for resident use. LPAs observed areas where lawn was not level with pavers in the backyard and Applicant agrees to fill these areas in prior to accepting residents in care. LPAs were granted access to backyard shed and observed furniture owned by the home owner from who they have a 5 year lease agreement. Windows, screens, and blinds were all observed in good repair.

Applicant will submit proof of liability insurance once home is active, post licensure. LPAs observed a facility sketch which accurately reflects the floor plan. Applicant was not approved for bedridden residents by the local fire department.

Continued on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ASHLEY'S CARE HOMES
FACILITY NUMBER: 486804288
VISIT DATE: 03/27/2025
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Continued on LIC809C...

Applicant has since had the fire door installed as instructed by the fire department in order to be approved for a fire clearance which allows for the acceptance of bedridden residents. Applicant will submit a new LIC200 and facility sketch to the Department to request a new fire clearance.

Component III orientation was conducted with the Applicant at facility where they conveyed knowledge and understanding of Title 22 regulations. The pre-licensing evaluation has been completed. License will be granted upon completion of a final review and approval from the Licensing Program Manager.

Exit interview conducted with Applicant, whose signature on this document confirms receipt.
NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025
LIC809 (FAS) - (06/04)
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