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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801647
Report Date: 05/26/2021
Date Signed: 05/27/2021 10:06:03 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ASHLEY'S MANOR IIFACILITY NUMBER:
565801647
ADMINISTRATOR:MARICAR LEEFACILITY TYPE:
740
ADDRESS:1013 SKEEL DRIVETELEPHONE:
(805) 419-4316
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:6CENSUS: 3DATE:
05/26/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:41 AM
MET WITH:Maricar LeeTIME COMPLETED:
01:45 PM
NARRATIVE
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This Case management visit was conducted to address the deficiencies noted during complaint control # 29-AS-20210524100952 investigation visit conducted on 5/26/2021.

During facility tour on 5/26/21 starting at 10:41 AM, LPA's observed Lysol anti-bacterial wipes, bathroom spray and disinfectant spray in a restroom accessible to residents. At 10:52 AM, LPA's observed unlocked cabinet that contained resident files. At 10:54 AM, LPA's observed Liquid Wrench silicone spray in the backyard accessible to residents. At 10:55 AM, LPA's observed a hedge trimmer in an unlocked shed in the backyard accessible to residents. At 11:38 AM, LPA's observed R1, R2, R3 Physicians Report and Appraisal Reports not currently dated.


Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D):

Exit interview conducted, todays reports reviewed and email to administrator.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ASHLEY'S MANOR II
FACILITY NUMBER: 565801647
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/28/2021
Section Cited

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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:...

This requirement is not met as evidenced by
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Based on LPA's observations, the licensee did not comply with the section cited above as toxic substances, gardening suppies, and disinfectant were observed throughout the facility accessible to residents which posed an immediate health risk to persons in care.
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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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2021
LIC809 (FAS) - (06/04)
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