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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610709
Report Date: 05/22/2026
Date Signed: 05/22/2026 01:47:40 PM

Document Has Been Signed on 05/22/2026 01:47 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ASHTON HOME LLCFACILITY NUMBER:
197610709
ADMINISTRATOR/
DIRECTOR:		ZHOU, PHILIPFACILITY TYPE:
740
ADDRESS:3322 ASHTON PLACETELEPHONE:
(818) 689-4358
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: 3DATE:
05/22/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Marialinda Naguiat - CaregiverTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Evelin Rios arrived to the facility above to conduct an unannounced annual required visit. LPA was greeted by a caregiver and granted access. Caregiver contacted the Licensee representative, Isaias Yin to inform him LPA was at the facility and the reason for the visit. Isaias informed LPA they would not be able to meet with LPA but would be available by telephone.

At 9:30am LPA conducted a tour of the physical plant and observed the following:

The facility is licensed for a capacity of six (6) residents. The fire clearance is approved for one (1) ambulatory resident in room #1, four (4) non-ambulatory residents in rooms #4, #5, #6, and one (1) bedridden resident in room #3. Room #4 can be shared. The facility also has a waiver granted for hospice care of two (2) residents.

At entry LPA observed a sign in sheet for visitors, thermometer, hand sanitizer and PPE supplies. LPA observed required posting through out the facility. The formal dining table sits the capacity of the facility and is in good repair. The facility keeps resident and staff records in a filing cabinet in the formal dining area. In the kitchen LPA observed there to be a sufficient supply of two-day perishable and seven-day non-perishable foods in the facility. The facility has the overflow of food stored in a second refrigerator and freezer in the garage. Food storage and preparation areas are clean and inaccessible to pests. The fire extinguisher is located in the kitchen and was last serviced on 01/07/2026. The medication and sharps were observed locked in kitchen cabinets. LPA observed a a small locked refrigerator on the kitchen counter used to store medication requiring refrigeration. LPA observed a second dining table with chairs. The living room has a television and recliners for residents. Doors leading to the outside have auditory alarms that were functioning properly. (Continue to LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2026
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ASHTON HOME LLC
FACILITY NUMBER: 197610709
VISIT DATE: 05/22/2026
NARRATIVE
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In the hallway LPA observed the thermostat that read 73°F and night lights leading to bathrooms.

The five (5) resident Bedrooms are appropriately furnished and have appropriate lighting. Bathrooms were appropriately supplied with hand soap, toilet paper and paper towels. Extra towels and linens were readily available in a hallway closet. The hot water temperature in two (2) out of three (3) bathrooms measured 114.6°F and 116.6°F, within regulation. The laundry room was observed locked and leads to the attached garage. All chemicals and detergents are kept in the laundry room inaccessible to residents in care. The backyard is fenced in, and LPA observed appropriate outdoor furniture, with covered shaded areas for residents. Dual smoke/carbon monoxide alarms were tested at 12:50 PM and observed to be operational.

LPA reviewed three (3) of three (3) resident records. Three (3) of three (3) resident records were incomplete. Two (2) of three (3) resident files were missing copies of admission agreements. Three (3) of three (3) resident files were missing copies of resident appraisals. Resident #1 (R1) does not have a medical assessment on file. Centrally stored medication and medication records were reviewed fro proper documentation. LPA reviewed two (2) staff files. Staff stated they had completed training but facility did not have orientation or staff training documentation. One (1) of two (2) staff did not have a health screening with TB results or first aid certification on file. LPA was not provided documentation that emergency drills were conducted quarterly by facility staff. Last documented drill was conducted 03/25/2025. LPA requested copies of the Certificate of Liability Insurance and Emergency Disaster Plan (LIC610E) be emailed to LPA.

Citations issued on LIC809-D during this visit.

Exit interview conducted. Appeal rights and a copy of this report provided to caregiver.

NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2026
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 05/22/2026 01:47 PM - It Cannot Be Edited


Created By: Evelin Rios On 05/22/2026 at 01:11 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ASHTON HOME LLC
FACILITY NUMBER: 197610709

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2026

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
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Based on record review the licensee did not comply with the section cited above in 1 out of 2 staff not having a health screening on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/05/2026
Plan of Correction
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Licensee agreed to have staff complete health screening and provide a copy of documentation to the deportment by POC due date.
Type B
Section Cited
CCR
87412(c)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 2 staff not having orientation and staff training documented as completed on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/05/2026
Plan of Correction
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Licensee agreed to complete training documentation and provide copies to the department by POC due 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.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Evelin Rios
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 05/22/2026 01:47 PM - It Cannot Be Edited


Created By: Evelin Rios On 05/22/2026 at 01:11 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ASHTON HOME LLC
FACILITY NUMBER: 197610709

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 2 staff not having first aid certification on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/05/2026
Plan of Correction
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Licensee agreed to send copy of first aid certification to the Department by POC due date.
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above in 3 out of 3 residents not having complete current records in the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/05/2026
Plan of Correction
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The Licensee agreed to complete missing documentation and provide copies to the Department by POC due 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.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Evelin Rios
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 05/22/2026 01:47 PM - It Cannot Be Edited


Created By: Evelin Rios On 05/22/2026 at 01:11 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ASHTON HOME LLC
FACILITY NUMBER: 197610709

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not conducting quarterly drills since March 2025 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2026
Plan of Correction
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Licensee agreed to complete drills and documentation of completion and provide copy to the Department by POC due date.
Type B
Section Cited
CCR
87458(a)
87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 3 residents did not have a medical assessment on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/05/2026
Plan of Correction
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2
3
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Licensee agreed to obtain a medical assessment for R1 and provide a copy of medical assessment to the Department by POC due 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.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Evelin Rios
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2026


LIC809 (FAS) - (06/04)
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