565801647-6-8-2023-29-AS-KDUK-CSLTX8-20230608150643

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801647
Report Date: 06/08/2023
Date Signed: 06/08/2023 03:08:08 PM

Document Has Been Signed on 06/08/2023 03:08 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

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:	06/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:12 PM
MET WITH:	Tina Marie Martinez		TIME COMPLETED:	03:10 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 12:12 PM. The LPA met with facility designee Tina Marie Martinez. Licensee was unavailable during today's visit. Entrance interview conducted.

The LPA, along with facility designee 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:

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.

RESTROOMS: The LPA observed 3 (three) restrooms in the facility; one is a shared restroom, one is a private restroom and one is designated for staff use. Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature was measured in the common resident restroom and measured 114.2 degrees Fahrenheit, which is within the required range.

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 extinguisher was observed to be fully charged and last serviced on 05/23/2022. During today's visit a new fire extinguisher was purchased and delivered to the facility. Smoke detector and carbon monoxide detectors were tested at 02:54PM and were functional at the time of the visit. Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

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
	VISIT DATE: 06/08/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

OUTDOOR SPACE: 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.

RESIDENT RECORD REVIEW: Began at 01:04PM, resident records were reviewed for documents including, but not limited to: physician's report, needs and service appraisal, and personal rights. Two (2) of five (5) resident records reviewed did indicate a TB test had been performed but results were not marked. Facility designee indicated TB tests had been administered and were negative and contacted the residents' responsible parties to obtain proof of negative TB tests. LPA will review documentation at a later date. All other records reviewed were in compliance with regulation at the time of the visit.

MEDICATION REVIEW: Began at 02:05PM. Medications for 4 (four) of 6 (six) residents were observed. Prescription medications reviewed were documented and labeled in accordance with regulation. However, 3 (three) of 4 (four) over the counter medications were not labeled per regulation.

INFECTION CONTROL: Not reviewed during today's visit.

STAFF RECORD REVIEW: Not reviewed during today's visit.

EMERGENCY DISASTER PREPAREDNESS: Not reviewed during today's visit.

INTERVIEWS: Interviews will be conducted during annual continuation visit.

No citations issued. Exit interview conducted. A copy of today's report was provided during the visit.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3