565801834-1-24-2023-29-AS-KDUK-CNDUWC-20230124145630

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801834
Report Date: 01/24/2023
Date Signed: 01/24/2023 02:57:27 PM

Document Has Been Signed on 01/24/2023 02:57 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 I		FACILITY NUMBER:	565801834
ADMINISTRATOR:	MARICAR LEE		FACILITY TYPE:	740
ADDRESS:	1277 BEDFORD DRIVE		TELEPHONE:	(805) 419-4323
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY: 6		CENSUS: 5	DATE:	01/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Maricar Lee		TIME COMPLETED:	03:05 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 01:05PM. This annual had a specific emphasis on infection control practices and procedures. The LPA initially met with staff Eufrecina Tabuena. Licensee Maricar Lee arrived at the facility at 01:13PM and discussed the reason for the visit. Entrance interview conducted. The LPA, along with Licensee, toured the physical plant areas inside and outside at 01:15PM to ensure there are no health and safety hazards. The following was observed: 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. At 01:27PM, in a common hallway restroom, water temperature measured at 125.6 degrees Fahrenheit. 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. The LPA observed the required postings in the common hallway. Fire extinguishers were observed to be serviced within the last year. Hardwired smoke detectors and carbon monoxide were tested at 01:30PM and Report Continued on LIC 809 - C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023

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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Document Has Been Signed on 01/24/2023 02:57 PM - It Cannot Be Edited

Created By: Kelly Dulek On 01/24/2023 at 02:12 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ASHLEY'S MANOR I	FACILITY NUMBER: 565801834
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as water temperature measured at 125.6 degrees Fahrenheit at 01:27PM, which poses an immediate safety risk to persons in care.
	POC Due Date: 02/01/2023
	Plan of Correction
1 2 3 4	During today's visit, Licensee adjusted the hot water heater and prior to LPA leaving the facility, water temperature measured within the required range. Licensee will also log water temperature readings for one week and send a copy of the log to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Kristin Heffernan

LICENSING EVALUATOR NAME:

Kelly Dulek

LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ASHLEY'S MANOR I	FACILITY NUMBER: 565801834
	VISIT DATE: 01/24/2023

NARRATIVE

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were functional at the time of the visit.

The backyard has a covered outdoor area equipped with furniture for resident use. There were 2 (two) water fountains noted, neither of which were running, but both did contain some standing water. Facility representative noted water had accumulated during the recent rains and that both would be drained to ensure resident safety. The garage was observed locked and contained locked storage cabinet for laundry supplies and emergency food supply.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable
and non-perishable food. 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 Licensee regarding the facility’s
infection control practices. 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 deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023

LIC809 (FAS) - (06/04)

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