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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001684
Report Date: 05/24/2024
Date Signed: 05/24/2024 10:50:47 AM

Document Has Been Signed on 05/24/2024 10:50 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 VILLA IIFACILITY NUMBER:
306001684
ADMINISTRATOR/
DIRECTOR:		SUSAN P. ASHLINGFACILITY TYPE:
740
ADDRESS:363 E. 20TH STREETTELEPHONE:
(949) 645-2431
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY: 6CENSUS: 6DATE:
05/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Waldo ContrerasTIME VISIT/
INSPECTION COMPLETED:
11:05 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 was greeted and granted entry by Staff Donald “Don” Willox and explained the purpose of the inspection. Administrator (AD) Waldo Contreras was notified of annual inspection and arrived at the facility at 8:50 a.m.

During the inspection LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following:

This is a one-story home with three resident bedrooms, one staff bedroom, three bathrooms, and attached one-car garage. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. The front porch has a shaded sitting area. LPA observed residents watching television in the living room and resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew; faucets and toilets were operational. Water temperature tested at 105 degrees Fahrenheit.

LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged with service tag dated September 15, 2023. Gas stove, microwave, washer, and dryer were all inspected and observed to be operable. Sharps were observed locked in a kitchen cabinet. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents. Medication cabinet was observed to be locked. LPA reviewed six resident files and three staff files. LPA interviewed residents and staff.

(Cont. LIC809-C)
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 II
FACILITY NUMBER: 306001684
VISIT DATE: 05/24/2024
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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: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
LIC809 (FAS) - (06/04)
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