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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200862
Report Date: 05/13/2022
Date Signed: 05/13/2022 10:54:08 AM

Document Has Been Signed on 05/13/2022 10:54 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:MANOR AT ASHLEY, THEFACILITY NUMBER:
079200862
ADMINISTRATOR:LIMBO, JOSEPHINEFACILITY TYPE:
735
ADDRESS:3225 ASHLEY WAYTELEPHONE:
(415) 650-6990
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 1DATE:
05/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Josephine Tumbaga, CaregiverTIME COMPLETED:
11:00 AM
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On 5/13//2022 at 9:25AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Josephine Tumbaga, Caregiver, and explained the purpose of the visit.. Josephine Limbo, Administrator, arrived at 10:35AM.

Upon entry, LPA's temperature was not checked. LPA observed screening station that contained hand sanitizer and COVID signage. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and backyard. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap, paper towel, and hand washing poster. Hot water temperature in the shared clients’ bathroom was measured at 112.8 degrees Fahrenheit. Fire extinguisher was last serviced on 11/20/2021.

During record review, LPA observed facility has a copy of Mitigation Plan on file. LPA observed food and paper supplies are sufficient.

The following forms are to be updated and submitted to CCLD by 5/20/2022:

-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2022
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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MANOR AT ASHLEY, THE
FACILITY NUMBER: 079200862
VISIT DATE: 05/13/2022
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Continued from LIC809.

-LIC610D Emergency Disaster Plan

The following deficiencies were observed:

-At 9:45AM, LPA observed drive thru gate locked with a combination padlock.
-At 9:48AM, LPA observed walk-thru gate had plastic zip-tie to lock gate. LPA was not able to open gate.

The following deficiencies were observed (see LIC809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/13/2022 10:54 AM - It Cannot Be Edited


Created By: Laura Hall On 05/13/2022 at 10:25 AM
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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MANOR AT ASHLEY, THE
FACILITY NUMBER: 079200862

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80072(a)(7)
80072 Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (7) Not to be locked in any room, building, or facility premises by day or not.
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 in having both exterior gates locked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/16/2022
Plan of Correction
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Administrator agreed to removed the combination padlock and the zip tie from both gates and submit a photo to CCLD by POC date. The padlock and zip tie was removed during visit. Deficiency cleared during visit.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2022


LIC809 (FAS) - (06/04)
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