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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300605448
Report Date: 01/24/2023
Date Signed: 01/24/2023 10:30:32 AM

Document Has Been Signed on 01/24/2023 10:30 AM - 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: 37DATE:
01/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Waldo ContrerasTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA met with Administrator (AD) Waldo Contreras and discussed the purpose of the inspection. During the inspection LPA Gutierrez and AD conducted a tour of the inside and outside of the facility, common areas, client rooms/units, kitchen, and observed the following:
This facility consists of three buildings. The central front building is one story and consists of three staff offices, one restroom, kitchen, and dining room. The two buildings located in the back are two story apartment complexes with one to two client bedrooms per unit. During the inspection LPA observed clients resting in their respective rooms and outside in the patio and courtyard area of the facility. A 2-day supply of perishable and a 7-day supply of non-perishable foods was observed during today’s visit. Upon record review LPA noted emergency care requirements were met. LPA observed the facility has a 30-day supply of PPE on hand. LPA observed hallways and walkways were free of obstruction.

LPA reviewed and confirmed facility policies and practices regarding resident screening, staff screening, visitation, COVID-19 testing, quarantine, isolation, cohorting, infection control training, PPE, staffing and staffing shortages.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2023
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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