565801834-1-30-2025-29-AS-VCOY-DDELYW-20250130081102

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801834
Report Date: 01/29/2025
Date Signed: 01/30/2025 08:11:09 AM

Document Has Been Signed on 01/30/2025 08:11 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	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	01/29/2025
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:02 AM
MET WITH:	Michelle Parr - Administrator		TIME VISIT/ INSPECTION COMPLETED:	05:00 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) Valeria Conway arrived at the facility unannounced to conduct a continuation of the required annual visit at 10:50 A.M. LPA met with caregiver Calixto “Alex” Calixtro and discussed the reason for the visit. Licensee, Maricar Lee, was contacted via telephone. Licensee arrived at 11:15 A.M. Administrator, Michelle Parr, joined the visit shortly after. Entrance interview conducted. Physical plant tour was conducted during the Annual visit. Today, a brief tour was conducted. No health and safety concerns were identified during today's tour. Today, LPA will conduct a medication and files review; the following was observed: RECORD REVIEW: Between 11:20 A.M. and 1:30 P.M., staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. 6 (six) resident records reviewed were complete and contained all required documents. Six (6) staff files reviewed were complete and contained all required documents. MEDICATION REVIEW: Began at 1:45 P.M. Medications for six (6) residents were observed. All medications are centrally stored in a locked closet at the end of the hallway between room #1 and room #5. Prescribed medications including PRN were labeled, stored, and inaccessible to residents in care. LPA observed discrepancies on the Centrally Store Medication and Destruction Log for two (2) residents. Continued from LIC 809-C

Desaree Perera	TELEPHONE: (818) 596-4347
Valeria Conway	TELEPHONE: (818) 454-0485
	DATE: 01/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025

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: 01/29/2025

NARRATIVE

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Continued from LIC 809

Additionally, during a medication audit, LPA observed that Resident #1 (R1) has a prescription for Tamoxifen 20MG tablet (90 qty) which was started on 01/05/2025. However, upon inspection of the pill bottle, LPA observed only 6 (six) pills remained. Licensee nor Administrator were able to provide an explanation for the missing medication.

INTERVIEWS: During today's visit, LPA interviewed two (2) caregivers.

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

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

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 01/30/2025 08:11 AM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87465(a)(6)

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not having an accurate count of medication for Resident #1 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/31/2025
	Plan of Correction
1 2 3 4	Provide training to staff authorized to complete the Centrally Stored Log on how to manage, store and administer medication. Also, complete frequent medication audits.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (818) 596-4347
Valeria Conway	TELEPHONE: (818) 454-0485
	DATE: 01/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025

LIC809 (FAS) - (06/04)

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