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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200862
Report Date: 04/13/2023
Date Signed: 04/13/2023 05:59:06 PM

Document Has Been Signed on 04/13/2023 05:59 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, 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:
(925) 775-4629
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 3DATE:
04/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Josephine Tumbaga, Direct Support ProfessionalTIME COMPLETED:
06:10 PM
NARRATIVE
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On 4/13/2023 at 03:00PM, Licensing Program Analysts (LPAs) L. Hall and L. Alexander conducted an unannounced annual 1-year required inspection. LPAs met with Josephine Tumbaga, Direct Support Professional (DSP) , and explained the purpose of the visit. LPA toured the facility with DSP, Joy Bisaha. The administrator currently holds a certificate (#6037851735) that expires on 6/19/2024. The facility’s fire clearance was approved for six (6) ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of four (4) total bedrooms which one (1) bedroom is used by staff, and two (2). All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 69 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 134.8 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. PPE and paper goods are sufficient. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Continued on LIC9099C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2023
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 04/13/2023 05:59 PM - It Cannot Be Edited


Created By: Laura Hall On 04/13/2023 at 05:08 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 the hot water temperature between 105 - 120 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/14/2023
Plan of Correction
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Administrator agreed to adjust temperature and take photo of thermometer with temperature and submit photo to CCLD by POC date.
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in having C1 medication inaccessible which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/14/2023
Plan of Correction
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Administrator agreed to remove medication from C1's room, store and lock it to make it inaccessible. Administrator will sign a self-certification stating that going forward medication will be locked.
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: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/13/2023 05:59 PM - It Cannot Be Edited


Created By: Laura Hall On 04/13/2023 at 05:08 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

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 debris located on side of passageway on left side of house which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2023
Plan of Correction
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Administrator agreed to remove carpet, cardboard boxes, toolbox, etc and submit photo to CCLD by POC 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023


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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: 04/13/2023
NARRATIVE
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Continued from LIC9099.

Smoke detectors/carbon monoxide were in operating condition during visit. Emergency Disaster Plan was last posted on 09/07/2020. First aid kit was observed to be complete. Fire drill was last conducted on 3/26/2023.

Three (3) staff records were reviewed, and all staff have criminal record clearance. All three (3) clients records reviewed. Two (2) of three (3) were complete. One (1) client moved in on 4/12/2023. LPAs also reviewed P & I.

The following forms to be updated and submitted to CCLD by 03/20/2023:
  • LIC 500 Personnel Report
  • LIC 400 Affidavit Regarding Client/Resident Cash Resources
  • LIC 402 Surety Bond
  • Client's roster
  • LIC 308 Designation of facility's Responsibility
  • LIC 610D Emergency disaster plan

LPA observed the following deficiencies:
  • At 3:30PM, LPAs observed hot water temperature in clients' shared bathroom measured 134.8 degrees F.
  • At 3:35PM, LPAs observed a 30-day pill organizer sitting on C1's night stand full of pills.
  • At 3:40PM, LPAs observed rolls of carpet, tool box that contained a hammer, screwdriver and other tools, degreaser, auto cleaner, a 5-gal bucket of carpet tacks with nails, and card board boxes on left side of house.


Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
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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: 04/13/2023
NARRATIVE
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Continued from LIC809C.

The following deficiencies were observed (see LIC 809D) 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: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
LIC809 (FAS) - (06/04)
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