197609088-1-24-2024-31-AS-ERIS-CZSURT-20240124144917

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609088
Report Date: 01/24/2024
Date Signed: 01/24/2024 02:49:36 PM

Document Has Been Signed on 01/24/2024 02:49 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:	01/24/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Imelda Castillo (Licensee)		TIME COMPLETED:	03:00 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 9:50 a.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility mentioned above to conduct a Required Annual Inspection. LPA was greeted by Licensee Imelda Castillo who granted access. Upon entry LPA observed required postings on the entry wall. LPA explained the reason for the visit. The inspection tool was used to complete the visit. At 10:00 a.m. LPA began a physical plant tour of the facility and the following was observed: 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 supply of food at the facility; properly stored. Knives and sharp objects stored in a locked cabinet. LPA observed a closet near the kitchen used as pantry. Properly labeled medications were locked in a cabinet in the kitchen. A small fridge meant for medications requiring refrigeration was observed locked. LPA observed a fire extinguisher in the kitchen area to be fully charged and last serviced 01/11/2024. 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. Bathrooms: There are three (3) bathrooms, one (1) of which 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 119.4 degrees Fahrenheit. (Continued on LIC809-C)

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024

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

FACILITY NAME: ASHTON CASTLE	FACILITY NUMBER: 197609088
	VISIT DATE: 01/24/2024

NARRATIVE

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Common Areas: These included the living area and dining area. The common areas were clean, clear of clutter and properly furnished. The facility has two dining tables with enough chairs to sit the capacity of the facility. Facility stores emergency kits fully stocked and available in dining area. The living area includes a television and a fireplace not in use secured with a glass screen.

Laundry Room: There is a designated laundry room which leads to the attached garage. The room was locked and inaccessible to residents in care. The garage has three freezers to store an overflow of food.

Surrounding Grounds: The outdoor had no visible hazards and all passageways were free of obstructions. There are shaded areas that provide shade for residents. LPA observed a side gate closed an unlocked.

Smoke and Carbon Monoxide Detector: Facility contracts a fire protection company to conduct annual fire alarm tests and fire extinguisher services. These services were provided on 01/16/2024 according to receipt records.

Resident/Staff Records: At approximately 11:00 a.m. (2) staff records were reviewed to insure compliance. Records for one (1) out of the two (2) staff were incomplete missing Health Screening with TB test and staff association to this facility. LPA's review of Guardian Background Check revealed Staff #1 (S1) is finger printed and background cleared, but missing association to the facility. According to Licensee, S1 does have the required documentation on file. During time of visit documents were not provided to LPA. At approximately 11:42 a.m. LPA reviewed five (5) out five (5) resident records to insure compliance.

Medications: Centrally stored medications are maintained locked in a kitchen cabinet. Centrally Stored Medication and Destruction Records were reviewed for proper documentation. Medication records were complete and updated. Facility also keeps Medication Administration Records (MAR).

Deficiencies issued during this visit (Refer to LIC809-D). Civil Penalty assessed (Refer to 421BG). Appeal rights provided. Exit Interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/24/2024 02:49 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or 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 one (1) of of two (2) staff records reviewed during visit revealed staff #1 (S1) was not associated to this facility, and a transfer request was not on file which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/25/2024
	Plan of Correction
1 2 3 4	Licensee has agreed to submit the request for transfer or complete association on the Guardian website. Licensee will provide documentation required for transfer or copy of association completed with an updated LIC500 by POC due 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.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/24/2024 02:49 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in one (1) out of two (2) staff records reviewed by not having on file staff #1 (S1's) Health Screening which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/02/2024
	Plan of Correction
1 2 3 4	Licensee has agreed to submit a heath screening report/exam to LPA 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.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024

LIC809 (FAS) - (06/04)

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