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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801834
Report Date: 03/13/2024
Date Signed: 03/13/2024 03:44:36 PM

Substantiated


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
03/08/2024 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 29-AS-20240308161112
FACILITY NAME:ASHLEY'S MANOR IFACILITY NUMBER:
565801834
ADMINISTRATOR:MARICAR LEEFACILITY TYPE:
740
ADDRESS:1277 BEDFORD DRIVETELEPHONE:
(805) 419-4323
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:6CENSUS: 5DATE:
03/13/2024
UNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Maricar Lee, Tina Marie Martinez, and Michelle ParrTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility is not kept free of rodents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek initiated a complaint investigation for the allegation listed above at 10:23AM. LPA intitally met with facility staff. Administrator/Licensee Maricar Lee and facility designees arrived shortly after the visit began. Entrance interview conducted.

LPA interviewed facility designee at 10:28AM, toured the facility at 10:45AM and took photographs, LPA interviewed staff at 01:15PM, 01:48PM, residents at 02:20PM and 02:24PM, and interviewed Licensee at 02:45PM. The following was then determined:

Interviews revealed that there have been rodents observed in the facility's garage and near one resident room. The facility staff has cleaned up some areas including food in the one resident room, in an attempt to limit the possibility of rodents returning to the facility. During today's visit, a contractor was present to observe the facility's air conditioning system and droppings were observed in the facility attic. Additional
Report Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 29-AS-20240308161112
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 I
FACILITY NUMBER: 565801834
VISIT DATE: 03/13/2024
NARRATIVE
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droppings were observed in the facility garage. Facility management had previously scheduled pest control services for tomorrow. Based on interview and record review, there is sufficient evidence to support the allegation, therefore the allegation that "facility is not kept free of rodents" is deemed SUBSTANTIATED at this time.

The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20240308161112
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 I
FACILITY NUMBER: 565801834
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/20/2024
Section Cited
CCR
87303(a)
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87303 (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include...services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
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Licensee indicated pest control services will be provided tomorrow and upon completion, Licensee will provide proof to CCL by POC due date.
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Based on observation and interview, the facility has had rodents observed in both the garage area as well as near a resident room and has evidence of rodent infestation in the attic, which poses a potential health and safety hazard to residents in care.
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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.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3