565801647-6-10-2022-29-AS-KDUK-CFA2UR-20220610174243

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801647
Report Date: 06/10/2022
Date Signed: 06/10/2022 06:49:05 PM

Document Has Been Signed on 06/10/2022 06:49 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
CCLD Regional Office,
, CA

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: 6	DATE:	06/10/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:25 PM
MET WITH:	Maricar Lee		TIME COMPLETED:	05:45 PM

NARRATIVE

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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 03:25 PM. This annual had a specific emphasis on infection control practices and procedures. The LPA initially met with facility/agency staff Delia Casayas. Licensee Maricar Lee arrived at 03:35PM and LPA Dulek discussed the reason for the visit.

The LPA, along with Licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room, family room, and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. Fire extinguishers were observed to be fully charged and last serviced on 05/23/2022.

The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. The garage was observed locked and contained the laundry area, as well as emergency food supply, PPE supply, and storage.

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 5 (five) total bedrooms; 4 (four) are designated for resident use and 1 (one) is designated as a staff room. The staff room was observed to be locked at the time of the visit.

Report Continued on LIC 809-C

SUPERVISOR'S NAME:	TELEPHONE:
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE:
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022

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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Document Has Been Signed on 06/10/2022 06:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: ASHLEY'S MANOR II	FACILITY NUMBER: 565801647
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(2)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above as when LPA arrived at the facility Staff #1 (S1) was working alone and has been working for 2 (two) days, but S1's criminal background clearance was not transferred to this facility prior to working with residents, which poses an immediate safety risk to persons in care.
	POC Due Date: 06/10/2022
	Plan of Correction
1 2 3 4	Licensee will provide LPA a copy of S1's LIC 508 and a photo ID during today's visit and LPA will transfer S1's criminal record clearance.

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as during the facility tour at 3:50PM, LPA and Licensee observed the following items in the shared bathroom: bleach, and wound cleanser which poses an immediate safety risk to persons in care.
	POC Due Date: 06/10/2022
	Plan of Correction
1 2 3 4	Items were secured during today's visit. Licensee will provide training to all staff on section 87705(f) and provide proof to CCL by 06/17/2022.

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:	TELEPHONE:
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE:
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022

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,
, CA

FACILITY NAME: ASHLEY'S MANOR II	FACILITY NUMBER: 565801647
	VISIT DATE: 06/10/2022

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RESTROOMS: The LPA observed 2 (two) restrooms in the facility; one is a shared restroom and one is a private restroom. Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature was measured in both resident restrooms and both were within the required range of 105 degrees Fahrenheit to 120 degrees Fahrenheit. At 03:50PM, LPA observed bleach in the shared restroom under the sink and wound cleanser was observed in the unlocked restroom cabinet.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Licensee regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening. LPA observed all staff and visitors to be wearing masks. The LPA observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

Staff #1 (S1) was the only staff present in in the facility upon LPA's arrival. Licensee interview revealed that S1 has been working at the facility since 06/09/2022 and was hired through an agency. LPA reviewed the facility's Guardian roster and discovered S1 does not have a criminal background clearance associated with the facility.

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

Civil penalties assessed in the amount of $200.00.

Exit interview conducted. Todays reports, appeal rights and civil penalties were reviewed and emailed to the Licensee.

SUPERVISOR'S NAME:	TELEPHONE:
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE:
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022

LIC809 (FAS) - (06/04)

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