565801647-1-12-2023-29-AS-JAPL-CN8VN9-20230119153443

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801647
Report Date: 01/12/2023
Date Signed: 01/12/2023 11:28:09 AM

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 Angel Ascencio

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: 5	DATE:	01/12/2023
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Maricar Lee		TIME COMPLETED:	11:35 AM

ALLEGATION(S):

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Facility staff are not assisting resident with ADLs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent visit to the facility above to deliver findings. LPA Ascencio met with Staff Edna Lara at 09:50 a.m. Licensee Maricar Lee arrived at the facility at 11:15 a.m. Entrance interview conducted.

On 05/24/2021, the Department received a complaint alleging that facility staff are not assisting resident with ADL’s. On 05/26/2021, LPA Ascencio and LPA Kelly Dulek conducted an interview with Licensee Maricar Lee at 11:05 a.m. Interview with Licensee revealed that there is a problem with Resident #1 (R1) and his care needs. R1 tends to call the staff every 5 – 10 minutes, during the day and night for assistance. Some of R1’s needs are to scratch their back, move R1’s leg, ask for food and change them very frequently. But, as staff are assisting R1, R1 begins to argue with staff and at times, hit staff and make them cry. Licensee added that staff have quit because of R1’s needs and behaviors. Additionally, Licensee stated that R1 requires two (2) persons assist with total care in activities of daily living (ADL).
Continued on LIC 9099 - C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

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: 01/12/2023

NARRATIVE

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Lastly, Licensee added that family is aware of the increased ADL’s and behavior issues of R1, and family is planning on moving R1 to another facility. A file review of R1’s medical chart, starting at 11:38 a.m., revealed that R1’s diagnosis is spastic hemiplegia affecting left side dominant, dysphagia, hypertension and requires full assistance with bathing, dressing, feeding, toiling and money management. Although, R1 is difficult and requires total care, staff continue to assist R1 in their ADL’s.

Later that same day, LPAs interviewed R1 starting at 12:20 p.m. Interview with R1 revealed that most of the time, R1 must yell out for assistance. R1 stated they tend to stay in their room most of the time since it is a big hassle for staff and R1 to get up. R1 also added that some days they are not happy with the care, other days, the care is great. R1 added that the staff do come in to help but they don’t do it the way R1 likes. LPAs noted R1 has a personal cell phone in their room. R1 stated the staff help with the phone and uses the cellphone to call family, friends and the Licensee.

Interviews with staff on 05/26/2021 and 01/03/2023 revealed that resident are assisted with hygiene, grooming, bathing, and eating daily. Further staff interviews revealed that two (2) residents are independent, one (1) resident needs minimal assistance with ADLs, and 2 residents need moderate assistance with ADLs such as eating, showering, transferring and toileting needs. Lastly, staff interviews revealed that staff have not refused assisting residents or have not heard of staff refusing to work with residents. Interviews on 01/03/2023 with five (5) residents starting at 11:40 a.m. revealed that the staff are very helping and take care of their wants and needs. Further interviews with residents also revealed that staff provide residents with meals, assist with toileting needs, assist with grooming and shower needs and assist with calling family or writing letters to family. During visits on 05/26/2021 and 01/03/2023, LPA observed 5 residents well groomed and taken care of with clean clothing. All residents seemed happy and expressed that their needs are being met by staff. Based on evidence gathered throughout the investigation, the allegation is unsubstantiated at this time.

Exit interview conducted. Licensee stated that an email copy of the report is preferred. LPA emailed copy to the Licensee.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

LIC9099 (FAS) - (06/04)

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