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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300605448
Report Date: 02/15/2022
Date Signed: 02/15/2022 02:40:45 PM

Document Has Been Signed on 02/15/2022 02:40 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ASHLING'S RESIDENTIAL VILLAFACILITY NUMBER:
300605448
ADMINISTRATOR:SUSAN ASHLINGFACILITY TYPE:
735
ADDRESS:362 E. 20THST.TELEPHONE:
(949) 645-1435
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY: 37CENSUS: DATE:
02/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Waldo Contreras, AdministratorTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced visit for the purpose of conducting a required annual inspection visit. LPA arrived at facility and was greeted by Waldo Contreras, Administrator and granted entry after undergoing the facility's COVID-19 screening. LPA explained the purpose of the visit.

At approximately 2:05pm, LPA accompanied by Administrator began the tour of the facility. There are currently 36 clients in care. The clients are observed relaxing in their lodging units and appear well taken care of. Facility appears to be clean, sanitary and free of odors in all areas inspected. LPA observed a check-in station right at the entrance of the main house. LPA observed the facility has COVID-19 Precautions posters, all required department postings, and hand washing signs throughout. LPA observed the emergency food supply and water. Facility has an adequate supply of PPE. LPA toured the outside of the facility and observed outdoor seating for the clients' enjoyment. Outdoor space is free of debris and well-maintained. All bedrooms were observed to have all required components.

The facility has completed the LIC808 Mitigation Plan, LPA Norman Woodridge reviewed and approved the plan on 08/02/2021. LPA Norman Woodridge emailed the signed and approved plan to the Administrator for their records.

Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with facility representative and a copy of this report was provided and left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2022
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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