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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801834
Report Date: 03/13/2024
Date Signed: 03/13/2024 03:41:38 PM

Document Has Been Signed on 03/13/2024 03:41 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 IFACILITY NUMBER:
565801834
ADMINISTRATOR:MARICAR LEEFACILITY TYPE:
740
ADDRESS:1277 BEDFORD DRIVETELEPHONE:
(805) 419-4323
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 5DATE:
03/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Maricar Lee, Tina Marie Martinez, and Michelle ParrTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 10:23AM. The LPA initially met with staff Eufrecina Tabuena. Licensee and facility Designees were contacted. Facility Designee arrived at 10:28AM, the Licensee Maricar Lee and other facility designee arrived shortly after the visit began. Entrance interview conducted.

The LPA, along with Facility Designee, toured the physical plant areas inside and outside at 10:45AM to ensure there are no health and safety hazards and the facility is in compliance with Title 22 regulation. The following was observed:

Fire extinguisher was observed to be fully charged and last serviced 07/17/2023. Hardwired combination carbon monoxide and smoke detectors and fire door were tested at 02:15PM and all were functional at the time of the visit.

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.

OUTDOOR SPACE: 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 designee noted water had accumulated during the recent rains. Licensee drained/removed water from both fountains during today's visit. At 10:45M and 10:49AM, respectively, both outdoor gates were observed to not fully open and not self-close nor self-latch. The garage was observed locked and contained locked storage cabinet for laundry supplies and separate food supply, as well as laundry area, and extra storage.

Report Continued on LIC 809 - C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2024
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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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: 03/13/2024
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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 designated for shared 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. Water temperature was measured in both shared resident restroom and private restroom and measured within the required range.

KITCHEN: Kitchen appliances appeared 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.

RECORD REVIEW: LPA reviewed 5 (five) resident files and 5 (five) staff files for documents including but not limited to physician's report, Admission Agreement, needs and service appraisal, personal rights, fingerprint background clearance, TB test, and staff training records. All files reviewed contained all required documents.

MEDICATION REVIEW: LPA reviewed medications for 2 (two) residents. Both 2 (two) of 2 (two) were observed to be properly stored, documented, and contained no discrepancies.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPA reviewed the facility's infection control plan. The facility's procedures relating to infection control are adequate. LPA also reviewed the facility's emergency disaster plan, which was completed and updated annually as required. Emergency disaster drills are conducted every 3 (three) months, with the last documented drill conducted in February 2024.

INTERVIEWS: During today's visit, LPA interviewed 2 (two) staff and 2 (two) residents.

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: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024
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Document Has Been Signed on 03/13/2024 03:41 PM - It Cannot Be Edited


Created By: Kelly Dulek On 03/13/2024 at 02:03 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: 03/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(h)
Care of Persons with Dementia
(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as 2 (two) gates were observed to be not self-closing nor self-latching which poses a potential safety risk to persons in care.
POC Due Date: 03/27/2024
Plan of Correction
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Licensee agreed to make adjustments to both side gates and to ensure that both are self-latching and self closing. Licensee with send photos or video to CCL by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 03/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2024


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