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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300605448
Report Date: 02/12/2024
Date Signed: 02/12/2024 03:49:30 PM

Document Has Been Signed on 02/12/2024 03:49 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
ORANGE COUNTY RO, 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:
02/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Henry Michaels, facility manager
Waldo Contreras, administrator		TIME COMPLETED:
04:00 PM
NARRATIVE
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This unannounced inspection has been conducted by Licensing Program Analysts (LPAs) Kevin Saborit-Guasch and Sean Haddad for the purpose of conducting a Required Annual Inspection. LPAs met with Administrator (AD) Waldo Contreras and discussed the purpose of the inspection.

LPA reviewed Infection Control requirements. At about 12:30PM, LPAs and AD conducted a tour of the inside and outside of the facility, common areas, client units, kitchen, and storage areas and observed the following: Structure: facility is a complex composed of three buildings in addition to storage sheds and a garage. Lodging units contain multiple rooms and bathrooms as well as common areas, and a laundry room in each building. Offices include a medication room, offices, and multiple storage closets in addition to two kitchens and food storage. There is a back yard with a large covered area for the use of clients. LPAs observed 10 staff and multiple clients present at the facility. LPAs inspected all client bedrooms. Client Bedrooms: the client bedrooms inspected are spacious and will easily accommodate the clients’ furnishings. Furniture for 37 client bedrooms inspected. Staff Bedrooms: there is one live-in staff unit with a fenced outdoor patio. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 114 and 118 degrees F. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, wired Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the storage closets. Medication room: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees have been paid. At about 1:45pm, LPAs reviewed 8 client files and 7 staff files, interviewed 8 staff and 8 clients, inspected medications for 8 clients, and inspected client money and ledgers for 8 clients. One type B citation was issued regarding the administrator HIV/TB training. An exit interview was conducted and a copy of this report was provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2024
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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Document Has Been Signed on 02/12/2024 03:49 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 02/12/2024 at 03:22 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ASHLING'S RESIDENTIAL VILLA
FACILITY NUMBER: 300605448

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviewed, the licensee did not comply with the section cited above as the two certified administrator could not provide proof of HIV/TB training done in the past two years which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2024
Plan of Correction
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Adminsitrators will update their training to include the HIV/TB training and will provide proof of completion to LPAs before the plan of completion due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Sheila Santos
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024


LIC809 (FAS) - (06/04)
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