197609088-12-29-2022-31-AS-ERIS-CMKSL4-20221229125743

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609088
Report Date: 12/29/2022
Date Signed: 12/29/2022 12:58:02 PM

Document Has Been Signed on 12/29/2022 12:58 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ASHTON CASTLE		FACILITY NUMBER:	197609088
ADMINISTRATOR:	CASTILLO, IMELDA M		FACILITY TYPE:	740
ADDRESS:	3322 ASHTON PLACE		TELEPHONE:	(818) 645-0652
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY: 6		CENSUS: 5	DATE:	12/29/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	IMELDA CASTILLO		TIME COMPLETED:	01:15 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	At 10:05 a.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility mentioned above to conduct a Required Annual/Infection Control inspection. LPA was greeted by Staff #1 (S1) who was wearing a mask and granted access. LPA called number on file and spoke with Licensee Imelda Castillo. Imelda stated Administrator is out of state and she will be meeting LPA at the facility as soon as she is able to. LPA explained the reason for the visit. LPA reviewed the Mitigation Plan approved 02/27/2021. The inspection tool was used to complete the visit. At 10:08 a.m. LPA began a physical plant tour of the facility and the following was observed: Infection Control: Upon arrival, LPA observed proper infection control signs outside the facility. LPA was granted access by staff #1 (S1) who was wearing a mask. Once inside LPA observed appropriate infection control signs and a sign-in visitor log with a self temperature reader in the entry. LPA observed a double keyed (double-cylinder) dead bolt lock on the front door entrance with keys hanging on the lock in the inside. Keys were observed to have keys to unlock cabinets in other parts of the house. LPA asked Licensee the reason for the lock and when it was added. According to Licensee it was added as a precaution in November or December when someone was knocking on the door at 3 a.m. two nights in a row. LPA observed masks, hand sanitizers and gloves available for use through out the facility. Licensee states facility has a 30 day supply of PPE. Kitchen: The kitchen was observed by LPA to be clean and the appliances and fixtures functional. LPA found a sufficient amount of two day perishable and seven day non-perishable food supply at the facility; properly stored. LPA found knives and sharp objects stored in a locked cabinet. Cleaners and chemical products are kept under the sink and are kept locked. Properly labeled medications were locked in a cabinet in the kitchen. A small fridge meant for medications was observed locked. LPA observed a fire extinguisher in the kitchen area to be fully charged and last serviced 06/28/2022.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022

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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ASHTON CASTLE	FACILITY NUMBER: 197609088
	VISIT DATE: 12/29/2022

NARRATIVE

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Bedrooms: There are a total of six (6) bedrooms, one (1) of which is designated for staff. One (1) out of the five (5) bedrooms designated for residents is shared. One (1) out of five (5) bedrooms designated for residents is currently vacant. All bedrooms were clean, properly furnished and had appropriate bedding and linens. Extra linens were available in a designated linen closet. All bedrooms had a trash can with a lid.

Bathrooms: There are three (3) bathrooms, one (1) of which is designated for staff use and another is located in the shared resident bedroom for private use. All bathrooms were clean, properly supplied with hand soap, paper towels, grab bars and shower mats. All bathrooms had hand washing signs and trash cans with tight fitting lids. Hot water temperature was measured at 119 degrees Fahrenheit.

Common Areas: These included the living room and dining area. The common areas were clean, clear of clutter and properly furnished. There is a designated laundry room which leads to the attached garage. The room was locked and inaccessible to residents in care.

Surrounding Grounds: There was furniture appropriate for outdoor use and no visible hazards. Covered shaded areas were observed. All passageways were free of obstruction. LPA observed a side gate closed an unlocked.

Smoke and Carbon Monoxide Detector: Licensee tested the fire alarm at 12:29 p.m. LPA observed detectors to be operational.

Deficiency issued during this visit. Appeal rights provided. Exit Interview conducted. Copy of report provided.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/29/2022 12:58 PM - It Cannot Be Edited

Created By: Evelin Rios On 12/29/2022 at 11:50 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ASHTON CASTLE	FACILITY NUMBER: 197609088
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87468.1(a)(6)

87468.1(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. 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 adding a double-keyed deadbolt to the front door entrance/exit kept locked when the key is removed from the door which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/31/2022
	Plan of Correction
1 2 3 4	Licensee will remove the double-key deadbolt and may switch to a single sided deadbolt with latch to open and close door without a key from the inside of the facility. Licensee will submit a picture of new deadbolt to LPA by POC due date 12/31/2022.

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.

SUPERVISOR'S NAME:

Eva Miller

LICENSING EVALUATOR NAME:

Evelin Rios

LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022

LIC809 (FAS) - (06/04)

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