565801647-5-26-2021-29-AS-JAPL-CN8VNA-20230119153444

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801647
Report Date: 05/26/2021
Date Signed: 05/26/2021 01:43:53 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/24/2021 and conducted by Evaluator Kelly Dulek

COMPLAINT CONTROL NUMBER: 29-AS-20210524100952

FACILITY NAME:	ASHLEY'S MANOR II		FACILITY NUMBER:	565801647
ADMINISTRATOR:	MARICAR LEE		FACILITY TYPE:	740
ADDRESS:	1013 SKEEL DRIVE		TELEPHONE:	(805) 419-4316
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	6	CENSUS: 3	DATE:	05/26/2021
		UNANNOUNCED	TIME BEGAN:	10:41 AM
MET WITH:	Maricar Lee		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Facility is not answering phone
Facility is restricting communication with family and friends

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Kelly Dulek and Angel Ascencio initiated a complaint investigation for the allegations listed above at 10:41AM. LPAs Dulek and Ascencio initally met with facility staff Edna Lara. Administrator Maricar Lee arrived at 11:00AM and LPAs discussed the reason for today's visit. Entrance interview conducted.

LPAs interviewed the Administrator at 11:05AM and again at 12:39PM, conducted a physical plant tour at 10:45AM, conducted staff and resident interviews between 11:58AM and 12:35PM. LPAs also conducted a file review at 11:38AM and gathered documents pertinent to the investigation.

Prior to visiting the facility and during today's visit, LPAs called the facility multiple times. Each time, facility staff answered the phone. Interviews revealed that there are two phone lines at the facility and both are accessible for resident use and to receive private phone calls. Administrator interview revealed that one of
Report Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
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.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210524100952

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 05/26/2021

NARRATIVE

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the phones had a connection problem one day, where a call was answered but then cut out. The staff returned the call immediately and was able to speak with the caller. A new phone was purchased and replaced right away. At all times, the facility had a second phone available and in use. Staff and resident interviews revealed phone calls are regularly answered promptly. Based on interviews and observation, there is insufficient evidence to support the allegation, therefore the allegation that "facility is not answering phone" is deemed UNSUBSTANTIATED at this time.

Resident and staff interviews revealed that Resident #1 (R1) has in-person visitors weekly or multiple times a week. LPAs observed that R1 has their own personal cell phone in their own room with a power cord accessible. Additionally, residents are able to make and receive private phone calls on the 2 (two) facility phone lines. Interviews revealed that residents have no communication restrictions and can contact whomever they like freely. Based on interviews and observation, there is insufficient evidence to support the allegation, therefore the allegation that "Facility is restricting communication with family and friends" is deemed UNSUBSTANTIATED at this time.

Exit interview conducted. A copy of the report and appeal rights were provided by email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
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

LIC9099 (FAS) - (06/04)

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