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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804288
Report Date: 08/22/2025
Date Signed: 08/22/2025 02:37:13 PM

Document Has Been Signed on 08/22/2025 02:37 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: 3DATE:
08/22/2025
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Omar Chiong-AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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At approximately 9:45 AM, Licensing Program Analyst (LPA) Star Stevenson arrived announced to conduct a post-licensing inspection and was greeted by administrator Omar Chiong. Facility is a Residential Care Facility for the Elderly (RCFE) licensed for six (6) residents, 6 of which can be non-ambulatory with a hospice waiver for three (3). Currently there are Three (3) residents in care.

At approximately 10:15 AM, LPA 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. LPA observed resident showers now have shower curtain rods and curtains and non-slip mats and grab bars are in place. LPA 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.

Cabinets in communal areas of the facility containing cleaning supplies and other items that could pose a risk were observed locked. Facility has a designated locked closet, as well as locked drawer and cabinet for centrally stored medications and resident, staff, and facility files. LPA observed first aid kit, PPE, other emergency supplies, activity schedule, and games available for resident use. LPA continues to recommended that applicant add additional, age appropriate activities for elderly residents like puzzles, hangman, crafts, music, coloring, pet visits, music visits etc. Facility has a fire extinguisher, which was last inspected 10/2024 and is fully charged and licensee was advised to arrange for re-inspection and tagging soon. Smoke and Carbon Monoxide detectors were tested and operational during inspection.

Continued on LIC809-C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2025
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 13
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: 08/22/2025
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..continued from LIC809...
The backyard now has level walkways and a shaded patio area and seating for resident use. A large and heavy stone counter top was observed to be leaning against a locked shed and licensee was advised to lay it flat on the ground or remove it to reduce potential risk to residents or staff in the event the stone fell over.

LPA conducted a review of five (5) of 5 staff records and three (3) of 3 resident records. Four (4) of five (5) staff files were missing paperwork with S1, S2, S3, S4 had no evidence of 40 hours of training and S5 had no evidence of on-going training since administrator classes, S3 had no LIC503 (health screening), and S4 and S5 had evidence of TB clearance. In addition, S1 was not associated in Guardian and criminally cleared to work, although had evidence that two attempts to get fingerprinted resulted in poor fingerprint testing with S1 leaving during my inspection to be re-fingerprinted. Licensee was asked to ensure that S1 did not return to work until cleared to work and associated to the facility on Guardian. Three(3) of 3 resident files determined all 3 were missing Consent for Emergency Medical Treatment (LIC627c) and signed Personal Rights (LIC613)

Licensee did not have current liability insurance and made a call to his insurance agent and paid for insurance during my inspection and will send in evidence of liability insurance by 08/28/2025.

Continued on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ASHLEY'S CARE HOMES
FACILITY NUMBER: 486804288
VISIT DATE: 08/22/2025
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Continued from LIC809C

Licensee was given Guardian brochure, as well as, Technical Support Program (TSP) brochure. In addition licensee was given copy of updated RCFE educational requirements for staff members, as well as, records to be maintained at all time for both staff and residents in care and technical violations and advisories were issued.

LPA obtained an updated LIC 500 Personnel Report today
Licensee to send in evidence of Liability insurance by Thursday 08/28/2025

No deficiencies were cited today.

Technical violations and advisories are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure follow CCR and the Health and Safety Code may result in deficiencies and civil penalty assessments during future inspections and/or case management visits.

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

DATE: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025
LIC809 (FAS) - (06/04)
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