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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801834
Report Date: 02/12/2026
Date Signed: 02/12/2026 03:25:08 PM

Document Has Been Signed on 02/12/2026 03:25 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ASHLEY'S MANOR IFACILITY NUMBER:
565801834
ADMINISTRATOR/
DIRECTOR:		MARICAR LEEFACILITY TYPE:
740
ADDRESS:1277 BEDFORD DRIVETELEPHONE:
(805) 419-4323
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 5DATE:
02/12/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Maricar LeeTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct the required annual visit at 9:15 A.M. The LPA initially met with caregiver Calixto “Alex” Calixtro and staff Eufrecina Tabuena. Licensee, Maricar Lee was contacted via telephone. At 10:10 A.M. facility designee, Michelle Viernes, arrived at the facility. Licensee arrived at 11:20 A.M. Entrance interview was conducted.

Beginning at 10:20 A.M., the LPA along with facility designee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 regulation. The following was observed:

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 were observed to be in good condition. The LPA observed the required postings in the common areas. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. The facility maintained a temperature of 72 degrees. LPA observed a working phone available for residents use whenever needed. Fire extinguisher was observed to be fully charged and last serviced 07/18/2025. LPA observed that fire extinguisher was mounted on the far wall of the common/TV area. Recliners, wheelchairs and other items were positioned in front of and around the extinguisher, obstructing direct access. LPA requested to relocate the fire extinguisher to a readily accessible location. Hardwired combination of carbon monoxide and smoke detectors and a fire door were tested at 10:46 A.M. and all were functional at the time of the visit. This facility doesn’t have a staff room; facility will provide 24/7 care.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2026
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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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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Document Has Been Signed on 02/12/2026 03:25 PM - It Cannot Be Edited


Created By: Valeria Conway On 02/12/2026 at 02:24 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: 02/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

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 side gate had a metal wire obstructing the lach preventing the gate from opening which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/12/2026
Plan of Correction
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Caregiver and designee immediately removed the metal wire from the gate latch. Staff verbalized understanding the importance of not obstructing emergency exits. POC Cleared
Type A
Section Cited
CCR
87615(a)(5)
Prohibited Health Conditions
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (5) Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as two residents who has no capacity for self-care and no record of an exception on file, which poses an immediate health and safety risk to residents in care.which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2026
Plan of Correction
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Licensee will read regulation cited and write a statement of understanding. Also, licensee will ask POA to contact a hospice agency to assess residents. If they do not qualify for hospice services, licensee will apply for an exception with CCL.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/12/2026 03:25 PM - It Cannot Be Edited


Created By: Valeria Conway On 02/12/2026 at 02:24 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: 02/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(i)
Reappraisals
(i) When there is significant change in condition, as defined in Section 87101, Definitions, or once every 12 months, whichever occurs first, the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative, if applicable, and appropriate facility staff, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as four out of five resident's needs and service plan were missing signatures which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2026
Plan of Correction
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Licensee wll collect signatures and submit proof to LPA before 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.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2026


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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ASHLEY'S MANOR I
FACILITY NUMBER: 565801834
VISIT DATE: 02/12/2026
NARRATIVE
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Continued from LIC 809-C

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.

BATHROOMS: Three (3) bathrooms were observed to be clean and sanitary and in operating condition. Showers were also observed to have grab bars and slip resistant mats and surfaces. The LPA observed sufficient amounts of soap and paper products in each restroom. Water temperature was measured in both shared resident bathrooms and private bathroom 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. LPA conducted a review of expiration dates on product labels. Knives and sharps were locked inside a toolbox on top of the kitchen counter. Hot water temperature was measured at 10:55 A.M. and measured 111.5 degrees Fahrenheit.

OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for residents’ use. There was a three-tier water fountain and a bird bath fountain noted. A small amount of standing water was present in both fountains due to rainfall from the previous day. During today’s visit, LPA requested that staff immediately dry out and empty both fountains. Facility has two (2) total side gates; both were observed to be self-closing and self-latching gates, however, during today’s visit the side gate located adjacent to the garage was observed to be secured with a metal wire, obstructing the gate from opening. LPA observed a clear passageways for emergency exit use. Facility provides sufficient space to accommodate both indoor and outdoor activities.

GARAGE: The Garage remains locked and inaccessible to the residents in care. There’s an area for the washer and dryer machine. Cleaning and laundry supplies were locked and properly storage inside a locked cabinet. A separate pantry with emergency supply was observed. Additionally, LPA observed a sufficient amount of emergency water.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ASHLEY'S MANOR I
FACILITY NUMBER: 565801834
VISIT DATE: 02/12/2026
NARRATIVE
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Continued on LIC 809-C

RECORD REVIEW: Between 11:30 A.M. and 1:05 P.M., staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. Five (5) resident records were reviewed. LPA observed that Resident #1 (R1) and Resident #2 (R2) have no capacity for self-care and they are not receiving hospice services. The LPA informed the licensee and designee that the facility needs to have an approved exception with the department for each resident that requires full care and is not on hospice. Additionally, LPA observed that four (4) out of five (5) residents did not have a signed needs and service plan form. Six (6) staff files reviewed were complete and contained all required documents.

MEDICATION REVIEW: Began at 1:15 P.M. Medications for five (5) residents were observed. All medications are centrally stored in a locked closet at the end of the hallway between room #1 and room #5. Prescribed medications including PRN were labeled, stored, and inaccessible to residents in care. During today’s visit LPA informed the licensee and designee that removing medication from their original packaging in advance of administration (pre-popping) is not permitted. LPA did not observe any discrepancies during today’s visit.

LPA obtained the following documents during today’s visit; Personnel Record (LIC500), Resident Roster (LIC9020A), current Liability Insurance, and infection control policy as well as the emergency disaster plan. Infection control and disaster plan forms were updated yearly as required by regulation. Last emergency disaster drill was conducted on 1/25/2026.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. An immediate civil penalty of $500 was issued.

Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026
LIC809 (FAS) - (06/04)
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