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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801647
Report Date: 10/12/2023
Date Signed: 10/12/2023 02:26:20 PM

Document Has Been Signed on 10/12/2023 02:26 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ASHLEY'S MANOR IIFACILITY NUMBER:
565801647
ADMINISTRATOR:MARICAR LEEFACILITY TYPE:
740
ADDRESS:1013 SKEEL DRIVETELEPHONE:
(805) 419-4316
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 6DATE:
10/12/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:07 PM
MET WITH:Michelle ParrTIME COMPLETED:
02:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a continuation of the required annual visit at 01:07 PM. The LPA met with facility designee Michelle Parr. Licensee/Administrator was unavailable during today's visit. Entrance interview conducted.

During today's visit the following was observed/reviewed:

STAFF RECORD REVIEW: LPA reviewed four (4) staff files for, but not limited to: health screening, TB test, training records and fingerprint clearance. All four (4) staff files observed were in compliance with regulation.

EMERGENCY DISASTER PREPAREDNESS: During today's visit, LPA reviewed the facility's emergency disaster plan. Emergency drills are conducted quarterly, with the last drill conducted on 08/04/2023. Emergency disaster plan was observed to be complete and updated annually, as required.

INFECTION CONTROL: During today’s visit, the LPA reviewed the facility's infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate.

INTERVIEWS: During today's visit, LPA interviewed staff and residents.

No citations issued. Exit interview conducted. A copy of today's report was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2023
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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