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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801647
Report Date: 05/06/2026
Date Signed: 05/07/2026 08:32:01 AM

Document Has Been Signed on 05/07/2026 08:32 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ASHLEY'S MANOR IIFACILITY NUMBER:
565801647
ADMINISTRATOR/
DIRECTOR:		MARICAR LEEFACILITY TYPE:
740
ADDRESS:1013 SKEEL DRIVETELEPHONE:
(805) 419-4316
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 6DATE:
05/06/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Maricar LeeTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit. LPA initially met with facility staff. Licensee/Administrator, Maricar Lee was contacted via telephone. At 9:35 A.M. Licensee and facility designee, Michelle Viernes, arrived at the facility. LPA explained the reason for the visit. Entrance interview was conducted.

Beginning at 10:15 A.M., LPA and 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. At 10:20 A.M., the smoke detectors were tested and functioned properly, as did the fire door in the hallway. At 10:22 A.M. the carbon monoxide detector was tested and functioned properly. The fire extinguishers were last serviced on 7/18/2025 and appeared fully charged.

OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for resident use. LPA observed that the backyard chairs were without cushions. During today’s visit, the Administrator purchased cushions for the chairs. The attached garage was observed locked and contained the laundry area, cleaning supplies, emergency food and water supply, extra food, and storage. LPA observed a non-functional water fountain on the front yard. At the time of the visit, no water was present in the fountain.

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 were observed to be in good condition. LPA observed the required postings in the common area, a working phone for residents’ use and a fireplace properly screened.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

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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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ASHLEY'S MANOR II
FACILITY NUMBER: 565801647
VISIT DATE: 05/06/2026
NARRATIVE
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Continued from LIC 809

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. The water temperature in the kitchen was initially measured at 123.8 degrees Fahrenheit, and warning signs were not identified. Administrator stated that residents do not use the kitchen faucet. During today’s visit the water heater temperature was adjusted. Technical Violation

BEDROOMS: 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 (two shared, two private) and one is designated as a staff room which was locked during the visit. During the plant tour, LPA observed that all residents’ beds were equipped with full bed rails.

RESTROOMS: LPA observed 3 (three) restrooms in the facility; one is a shared restroom, one is a private restroom, and one is the staff/visitor restroom. Restrooms were clean, sanitary and in operating condition with grab bars and slip-resistant surfaces. Water temperature was measured in all resident restrooms and measured within the required range.

STAFF AND RESIDENT RECORDS: Between 11:20 A.M. and 2:30 P.M. LPA reviewed records for 6 (six) residents and four (4) staff including the Administrator. During the record review, the following was observed; one resident is currently receiving hospice services, Resident #3 is bedridden, and the facility does not have and approved fire clearance for bedridden residents. LPA provided the necessary information to contact the Fire Marshal and LIC 200.

MEDICATIONS: LPA reviewed medications for four (4) residents. Medications appear to be given as prescribed and documented per regulation. LPA observed that medication was being pre-popped in advanced if administration. During today’s visit LPA informed the licensee and designee that removing medication from their original packaging in advance of administration (pre-popping) is not permitted.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2026
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ASHLEY'S MANOR II
FACILITY NUMBER: 565801647
VISIT DATE: 05/06/2026
NARRATIVE
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Continued from LIC 809-C

Furthermore, five (5) out of six (6) residents’ Needs and service plan were outdated, with some missing the responsible representative’s signature. Additionally, three (3) out of six (6) residents has no capacity for self-care and are no longer on hospice. The Administrator stated that residents were recently discharged from hospice. The LPA informed the Administrator that the facility needs to have an approved exception with the department for each resident that requires full care and is not on hospice. Personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All personnel files were complete.

The LPA obtained the following documents at the time of visit: Personnel Report (LIC500), Resident Roster (LIC9020), last emergency disaster drill, and proof of current facility’s liability insurance.

Additionally, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. Emergency disaster drills are conducted quarterly, with the last fire drill conducted on 04/23/2026.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809) Administrator was informed that failure to correct the deficiencies may result in civil penalties.

An immediate civil penalty of $500 for a violation of the facility’s fire clearance was issued (Refer to LIC 412M). The Licensee understands that continued violation of the facility’s fire clearance may result in additional civil penalties.

Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2026
LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 05/07/2026 08:32 AM - It Cannot Be Edited


Created By: Valeria Conway On 05/06/2026 at 03:26 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: 05/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by having a bedridden resident in room #3. Facility license is approved for 6 non-ambulatory residents only which poses an immediate health, safety risk to persons in care.
POC Due Date: 05/07/2026
Plan of Correction
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Provide a new LIC 200 and contact Fire inspector to get a new fire clearance including bedridden residents if possible. Email confirmation will be sent to LPA before POC due date. If new fire clearance is granted, LPA will print a new license.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/07/2026 08:32 AM - It Cannot Be Edited


Created By: Valeria Conway On 05/06/2026 at 03:26 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: 05/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not having current needs and service plan with responsible parties' signatures which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/21/2026
Plan of Correction
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By POC due date, Licensee will revise and complete new needs and service plans, get signatures from representatives and submit copies to LPA.
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as all residents had full rails and only one resident is receiving hospice care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/21/2026
Plan of Correction
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Licensee will remove full bedrails and obtain prescription for 1/2 rails for all 5 residents not receiving hospice services. A picture will be send to LPA before POC due date unless resident is admitted to hospice services.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2026


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 05/07/2026 08:32 AM - It Cannot Be Edited


Created By: Valeria Conway On 05/06/2026 at 03:26 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: 05/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87615(a)(5)
Prohibited Health Conditions
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (5) Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as 3 out of 6 residents has no capacity for self-care and is not on hospice and the facility does not have an approved exception with the Department, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/21/2026
Plan of Correction
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Licensee will contact family and physicians to assess residents to confirm if they are hospice candidates or if they need an exception. If they are admitted to hospice, licensee will submit plan of care and full bed rail note and if they don't meet criteria, licensee will submit an exception to LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2026


LIC809 (FAS) - (06/04)
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