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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200862
Report Date: 04/17/2024
Date Signed: 04/17/2024 04:05:26 PM

Document Has Been Signed on 04/17/2024 04:05 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/
DIRECTOR:		LIMBO, JOSEPHINEFACILITY TYPE:
735
ADDRESS:3225 ASHLEY WAYTELEPHONE:
(925) 775-4629
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 2DATE:
04/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:10 PM
MET WITH:Mark Bonete, Direct Support ProfessionalTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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On 4/17/2024 at 2:10PM, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual required inspection. LPA met with Mark Bonete, Direct Support Professional, and explained the purpose of the visit. 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, garage, and back yard. The facility consists of four (4) bedrooms and two (2) bathrooms. One (1) room occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 71 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 102.0 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 supply of non-perishable and 2-day of perishable foods.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2024
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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MANOR AT ASHLEY, THE
FACILITY NUMBER: 079200862
VISIT DATE: 04/17/2024
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Continued from LIC809.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was purchased on 4/26/2023. Emergency Disaster Plan was last posted on 8/11/2022. First aid kit was observed to be complete. Fire drill was last conducted on 4/8/2024.

LPA reviewed two (2) staff records all both were incomplete. The other staff records was not available for review. LPA reviewed both client records and both were complete. LPA also review P & I and a sample of medication.

The following forms to be updated and submitted to CCLD by 4/24/2024:
  • LIC 500 Personnel Report
  • LIC 400 Affidavit Regarding Client/Resident Cash Resources
  • LIC 402 Surety Bond
  • LIC610D Emergency disaster plan (last page)
  • LIC308 Designation of facility responsibility
  • Update facility sketch to show staff room


LPA observed the following deficiency:
  • At 3:05pm, LPA observed during record review facility did not have all staff records available for review.


Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of appeal rights and this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/17/2024 04:05 PM - It Cannot Be Edited


Created By: Laura Hall On 04/17/2024 at 03:52 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: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(c)
80066 Personnel Records

(c) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. removal of records shall be subject to the following requirements:

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 in having staff records available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2024
Plan of Correction
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Administrator agreed to complete and have all staff records available for review, and submit a self-certification that it has been completed 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: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024


LIC809 (FAS) - (06/04)
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