565801834-1-29-2025-29-AS-VCOY-DDDKUT-20250129071317

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801834
Report Date: 01/28/2025
Date Signed: 01/29/2025 07:13:26 AM

Document Has Been Signed on 01/29/2025 07:13 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 I		FACILITY NUMBER:	565801834
ADMINISTRATOR/ DIRECTOR:	MARICAR LEE		FACILITY TYPE:	740
ADDRESS:	1277 BEDFORD DRIVE		TELEPHONE:	(805) 419-4323
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY: 6		CENSUS: 46	DATE:	01/28/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:50 PM
MET WITH:	Michelle Parr - Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:30 PM

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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 12:50 P.M. The LPA initially met with caregiver Calixto “Alex” Calixtro and staff Eufrecina Tabuena. Administrator, Michelle Parr, was contacted via telephone. Administrator arrived at 2:24 P.M. Entrance interview conducted.

Beginning at 1:25 P.M., the LPA started reviewing records which included the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills conducted quarterly as per regulation; the last one being a earthquake and fire drill on 12/13/2024. Fire extinguisher was observed to be fully charged and last serviced 07/29/2024. Hardwired combination carbon monoxide and smoke detectors and fire door were tested at 2:15 P.M. and all were functional at the time of the visit. This facility doesn’t have a staff room, facility will provide 24/7 care.

The LPA, along with caregiver, toured the physical plant areas inside and outside at 1:45 P.M. to ensure there are no health and safety hazards and the facility is in compliance with Title 22 regulation. The following was observed:

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common hallway. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. The facility maintained a comfortable temperature of 71 degrees. LPA observed a working phone available for residents use whenever needed.

Continued on LIC 809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025

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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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 I	FACILITY NUMBER: 565801834
	VISIT DATE: 01/28/2025

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Continued from LIC 809-C

OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for resident use. There were 2 (two) water fountains noted, neither of which were running. Facility has two total gates; both were observed to be self-closing and self-latching gate with clear passageways for emergency exit use. Facility provides sufficient space to accommodate both indoor and outdoor activities.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 5 total bedrooms – one (1) bedroom is designated for shared resident use and four (4) are private.

RESTROOMS: Three (3) restrooms were observed to be clean and sanitary and in operating condition. Showers were also observed to have grab bars and slip resistant mats and surfaces. The LPA observed sufficient amounts of soap and paper products in each restroom. Water temperature was measured in both shared resident restroom and private restroom and measured within the required range.

KITCHEN: Kitchen appliances appeared in operable condition. The facility has a sufficient supply of perishable and non-perishable food. LPA conducted a review of expiration dates on product labels. Knives and sharps were locked inside a toolbox on top of the kitchen counter. Hot water temperature was measured at 2:10 P.M. and measured 112.2 degrees Fahrenheit.

GARAGE: The Garage remains locked and inaccessible to the residents in care. The garage contained locked storage cabinet for cleaning and laundry supplies, which were properly stored at the time of the visit. A separate food supply with emergency food was observed, as well as laundry area, and extra storage. Additionally, LPA observed an adequate amount of emergency water.

INTERVIEWS: During today's visit, LPA interviewed one (1) resident. the resident interviewed stated that the staff treat them well and are attentive to their needs. The resident had no concerns with the facility.

Continued onLIC 809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025

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 I	FACILITY NUMBER: 565801834
	VISIT DATE: 01/28/2025

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Continued from LIC 809-C

A Guardian system check for criminal background clearance was conducted during today’s visit. All staff have received a criminal background clearance.

Due to time constraints LPA will return at a later date to conduct medication review record review. During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and liability insurance.

Exit interview conducted and copy of the report was issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025

LIC809 (FAS) - (06/04)

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