079200862-4-8-2025-15-AS-LHAL-DFK2GR-20250408172334

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200862
Report Date: 04/08/2025
Date Signed: 04/08/2025 05:23:58 PM

Document Has Been Signed on 04/08/2025 05:23 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, THE		FACILITY NUMBER:	079200862
ADMINISTRATOR/ DIRECTOR:	LIMBO, JOSEPHINE		FACILITY TYPE:	735
ADDRESS:	3225 ASHLEY WAY		TELEPHONE:	(925) 775-4629
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY: 6		CENSUS: 2	DATE:	04/08/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:20 PM
MET WITH:	Mark Bonete, Direct Support Professional		TIME VISIT/ INSPECTION COMPLETED:	05:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 4/8/2025 at 3:20PM, 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 (#7032337735) that expires on 6/19/2026. 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 68 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 98.6 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster and soap observed at all hand washing stations. The supply of extra bedding and linen was available for residents. Continued on LIC809C.

NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Laura Hall
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/08/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

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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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: 04/08/2025

NARRATIVE

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Continued from LIC809.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was purchased on 12/18/2024. First aid kit was observed to be complete. Fire drill was last conducted on 11/7/2024.

LPA reviewed four (4) staff records all were current and complete. LPA reviewed both client records and both missing appraisal needs and services plan. LPA also review P & I.

The following forms to be updated and submitted to CCLD by 4/15/2025:

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

LPA observed the following deficiencies:

At 4:22pm, LPA observed during tour 3 bins with clothing, 4 tires, 2 bathroom cabinets, shelving, bins with tools, and shed missing door (unlocked).

At 4:22pm, LPA observed during tour 3 bins with clothing, 4 tires, 2 bathroom cabinets, shelving, bins with tools, and shed missing door (unlocked).

Continued on LIC809C.

NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Laura Hall
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/08/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

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: 04/08/2025

NARRATIVE

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Continued from LIC809C.

At 4:30pm, LPA observed facility did not have a 7-day supply of non-perishables and 2-day perishable food. LPA observed 3 oranges, a bag of hamburger buns, some grapes, plenty of milk, a 6-pack of canned fruit. No canned vegetables, milk, juice, bread. Facility had plenty of meat.

Deficiencies are 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.

NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Laura Hall
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/08/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/08/2025 05:23 PM - It Cannot Be Edited

Created By: Laura Hall On 04/08/2025 at 05:00 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: 04/08/2025

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having passageways with bins of tools, shelving, 4 tires, 3 bins with clothing, and the shed with broken door which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/15/2025
	Plan of Correction
1 2 3 4	Administrator agreed to remove all items, fix broken door on shed so it will lock, and submit photos to CCLD by POC date.

Type B

Section Cited

CCR

85076(d)(1)

Food Service

(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in having a 7-day supply of perishable and 2-day non perishable foods which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/10/2025
	Plan of Correction
1 2 3 4	Administrator agreed to purchase food and submit a picture of food and receipt to CCLD by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:

	Laura Hall
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/08/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/08/2025 05:23 PM - It Cannot Be Edited

Created By: Laura Hall On 04/08/2025 at 05:00 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: 04/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85068.3(a)

Modifications to Needs and Services Plan

(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in having an appraisal needs and services plan for each client which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/15/2025
	Plan of Correction
1 2 3 4	Administrator agreed to prepare an appraisal needs and services plan for each client and submit a self-certification that it has been completed to CCLD by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:

	Laura Hall
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/08/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

LIC809 (FAS) - (06/04)

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