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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801647
Report Date: 08/16/2021
Date Signed: 08/16/2021 06:48:19 PM

Document Has Been Signed on 08/16/2021 06:48 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 IIFACILITY NUMBER:
565801647
ADMINISTRATOR:MARICAR LEEFACILITY TYPE:
740
ADDRESS:1013 SKEEL DRIVETELEPHONE:
(805) 419-4316
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 0DATE:
08/16/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:42 PM
MET WITH:Maricar LeeTIME COMPLETED:
06:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kelly Dulek initiated a Case Management – Deficiencies visit for the purpose of issuing citations for concerns identified during the course of a Technical Advice visit and numerous phone conversations with the Licensee. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted telephonically with Maricar Lee, the facility licensee.

During daily telephone conversations the week of 8/9 – 8/13/2021, as well as during a Technical Assistance visit with Ventura County Public Health (VCPH) on site at another of the Licensee's facilities and CCL joining virtually, Licensee Maricar Lee refused to re-admit Resident #1 (R1) from the hospital. Licensee stated there was insufficient staffing for R1 at the facility. CCL provided staffing resources for the Licensee, who the LPA confirmed did in fact have staff available for COVID positive residents. The Licensee indicated there was no room available for R1 at the facility; however, at the time of the Licensee’s statement, no residents were currently residing at the facility and only 4 residents were residing at another of the Licensee’s facilities, which has a licensed capacity of 6. VCPH and the hospital discharge planner indicated R1 was ready for discharge from the hospital as of 8/9/2021. As of today, the resident is still admitted to the hospital and has yet to return to the facility.

The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. A telephonic exit interview was conducted. A copy of the report and appeal rights were provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2021
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
Document Has Been Signed on 08/16/2021 06:48 PM - It Cannot Be Edited


Created By: Kelly Dulek On 08/16/2021 at 02:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ASHLEY'S MANOR II
FACILITY NUMBER: 565801647

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/16/2021
Section Cited
HSC
1569.269(a)(22)

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1569.269 Enumerated rights; severability (a) Residents... have all of the following rights: (22) To be protected from involuntary transfers, discharges, and evictions... “involuntary” means a transfer, discharge, or eviction that is initiated by the licensee, not by the resident.
This requirement is not met as evidenced by:
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Licensee understands she needs to readmit the resident, per the hospital's instructions.
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Based on interview, the Licensee transfered R1 to the hospital and refused re-admission to the facility, which poses an immediate threat to the health and safety of residents in care.
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Type A
08/17/2021
Section Cited
CCR87405(d)

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87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
This requirement is not met as evidenced by:
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Licensee has agreed to do the following:
1. Schedule a training on conduct Regulation 87405. Training must be conducted by an approved vendor.
2. Submit a letter to CCLD indicating the vendor's name, address, phone number, and date of the training.
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Based on interview and observation, the licensee/administrator was unable to provide staffing and refused to allow R1 to return to the facility upon hospital discharge, which causes an immediate safety and personal rights risk to residents in care.
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Training must be completed by 8/31/2021.
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 Heffernan
LICENSING EVALUATOR NAME:Kelly Dulek
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2021


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/16/2021 06:48 PM - It Cannot Be Edited


Created By: Kelly Dulek On 08/16/2021 at 06:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ASHLEY'S MANOR II
FACILITY NUMBER: 565801647

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/17/2021
Section Cited
CCR
87468.1(a)(2)

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidenced by:
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Licensee has agreed to do the following:
1. Schedule a training on conduct Regulation 87468.1. Training must be conducted by an approved vendor.
2. Submit a letter to CCLD indicating the vendor's name, address, phone number, and date of the training.
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Based on interview and observation, Licensee did not allow R1 to return to R1's room at the facility when the hospital requested discharge, which poses an immediate personal rights risk to residents in care.
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Training must be completed by 8/31/2021.

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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 Heffernan
LICENSING EVALUATOR NAME:Kelly Dulek
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2021


LIC809 (FAS) - (06/04)
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