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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801834
Report Date: 03/15/2022
Date Signed: 03/21/2022 08:48:09 AM

Document Has Been Signed on 03/21/2022 08:48 AM - 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 IFACILITY NUMBER:
565801834
ADMINISTRATOR:MARICAR LEEFACILITY TYPE:
740
ADDRESS:1277 BEDFORD DRIVETELEPHONE:
(805) 419-4323
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 5DATE:
03/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:04 AM
MET WITH:Maricar LeeTIME COMPLETED:
12:15 PM
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Licensing Program Analysts (LPA) Angel Ascencio arrived at the facility unannounced to conduct a required
annual visit at 11:04 a.m. This annual had a specific emphasis on infection control practices and procedures.
The LPA met with Administrator Maricar Lee and discussed the reason for the visit. The LPA, along with
Administrator, toured the physical plant areas inside and outside at 11:07 a.m. to ensure there are no health
and safety hazards. Entrance interview conducted.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean
linens, appropriate furnishings and sufficient lighting. There are 5 total bedrooms – one (1) bedroom is
shared for resident use and four (4) are private.

RESTROOMS: 3 restrooms were observed to be clean and sanitary and in operating condition. Showers were
also observed to have grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap and
paper products in each restroom, as well as hand washing posters.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good
condition. At the time of the visit, common seating area and dining room furniture was observed to be in good
condition. Chairs were observed to be at least 6 (six) feet apart for social distancing. The LPA observed the
required postings in the common hallway. Fire extinguishers were observed to be serviced within the last
year. Smoke detectors and carbon monoxide was observed to be in operable condition at the time of visit.

The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of
water noted. The garage was observed locked and contained locked storage cabinet for laundry supplies and emergency food supply.

Continued on LIC 809 - C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2022
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 I
FACILITY NUMBER: 565801834
VISIT DATE: 03/15/2022
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KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable
and non-perishable food. Water temperature was observed to be within normal limits. All knives and cleaning
supplies were observed to be locked and properly stored at the time of the visit.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s
infection control practices at 11:30 a.m. There is 1 entry into the facility. Upon entry, the facility has a central
point for symptom screening. LPA noted that the facility is allowing visitors for both indoor and outdoor
visitation. The LPA observed an adequate supply of Personal Protective Equipment (PPE). The facility’s
cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection
control are adequate.

The following recommendations were made:

- Post recent PINS to educate staff, residents and visitors on ongoing changes from the Department.

No citations were issued during today’s visit. Exit interview conducted. A copy of the report was provided via
email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022
LIC809 (FAS) - (06/04)
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