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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001684
Report Date: 03/01/2022
Date Signed: 03/01/2022 04:53:21 PM


Document Has Been Signed on 03/01/2022 04:53 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 VILLA IIFACILITY NUMBER:
306001684
ADMINISTRATOR:SUSAN P. ASHLINGFACILITY TYPE:
740
ADDRESS:363 E. 20TH STREETTELEPHONE:
(949) 645-2431
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY:6CENSUS: 6DATE:
03/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:20 PM
MET WITH:Waldo Contreras, AdministratorTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit in order to conduct a required annual inspection. LPA arrived at facility, was greeted by Administrator Waldo Contreras and granted entry after being temperature checked.

At approximately 4:30pm, LPA accompanied by Administrator began the tour of the facility. There are currently six (6) residents in care. The residents are observed relaxing in the common areas or in their bedrooms and appear well taken care of. Facility appears to be clean, sanitary and free of odors in all areas inspected. Each bedroom is observed to have all required components and bathrooms are equipped with grab bars and slip mats.
LPA observed temperature checks are being documented for visitors, staff and clients. LPA observed the facility has COVID-19 Precautions posters, all required department postings and hand washing signs posted throughout. LPA observed a sufficient supply of food and water. Facility has an adequate supply of PPE in the attached garage.
LPA toured the outside of the facility and observed outdoor seating for the residents' enjoyment. Outdoor space is free of debris and well-maintained with self-latching gates that can easily be opened. The facility has completed and submitted their LIC808 Mitigation Plan which has been approved by LPA Norman Woodridge on 08/04/2021.

Based on the observations made during today’s visit, no deficiencies are being cited 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.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2022
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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