565850342-4-3-2025-29-AS-ECOZ-DFDQ44-20250403114944

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850342
Report Date: 04/03/2025
Date Signed: 04/03/2025 11:50:34 AM

Document Has Been Signed on 04/03/2025 11:50 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:	AMYLEW MANOR 2		FACILITY NUMBER:	565850342
ADMINISTRATOR/ DIRECTOR:	SORATORIO, EMMANUEL		FACILITY TYPE:	735
ADDRESS:	1138 MELITO DR		TELEPHONE:	(805) 890-0597
CITY:	OXNARD	STATE: CA	ZIP CODE:	93030
CAPACITY: 6		CENSUS: 6	DATE:	04/03/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Amalia Saratorio/Sahlee Gonzales		TIME VISIT/ INSPECTION COMPLETED:	12:05 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	At 08:00 a.m. Licensing Program Analysts (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. When the LPA arrived, there were no clients or staff present. The LPA contacted Co-Administrator Amalia Soratorio who arrived approximately at 09:00 a.m. LPA was informed Janica Soratorio was the new administrator and documents had been sent to the RO. Administrator authorized assistant administrator Sahlee Gonzales to sign report. At 09:15 a.m., the LPA and the Administrator conducted a tour of the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a single-story residence that consists of four (4) resident bedrooms, and two (2) bathrooms. The home is vendored by Tri-Counties Regional Center as a level 4-I home. The LPA observed fire extinguishers at the home, which were fully charged and last serviced 10/04/2024. All smoke alarms and carbon monoxide detectors were tested, and functioned properly. LPA observed all required postings in the living room of the home. Kitchen: During the facility tour the kitchen appeared clean and the appliances and fixtures functional. The LPA observed a sufficient supply of perishable and non-perishable food at the facility; Sharp objects and cleaning supplies are stored in a in a locked cabinet under the sink and in an additional locked cabinet in the kitchen. Food is prepared based on a menu. Snacks and beverages are always available for clients. Bedrooms: The LPA observed all four client bedrooms properly furnished with at least one chair, nightstand and sufficient lighting for each client. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Report will continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025

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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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.

LIC809 (FAS) - (09/23)

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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: AMYLEW MANOR 2	FACILITY NUMBER: 565850342
	VISIT DATE: 04/03/2025

NARRATIVE

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Bathrooms: The LPA observed all restrooms to be clean, and properly supplied. Residents have sufficient supplies for personal hygiene. The water temperature in the resident’s communal restroom was measured at 111.5 degrees Fahrenheit.

Common Areas: These included the living, and dining area. The common areas were checked for cleanliness and furniture was checked for functionality. There is a fireplace in the dining room, which is covered with a screen. The facility maintained a comfortable temperature of 69 degrees. There were no obstructions and/or tripping hazards throughout the home.

The garage/Surrounding Grounds (Outdoors): The LPA observed the garage, where the emergency food and water is stored. The garage is used to store additional supplies. Additional cleaning supplies are stored in the garage in locked cabinets inaccessible to clients in care. The garage is unlocked. The LPA observed appropriate outdoor furniture with a shaded area for clients in the backyard. There are no bodies of water on the premises.

Record Review: At 09:30 a.m., a review of facility files was initiated. Facility records are stored in a locked cabinet in the dinning room. The LPA observed documentation of Infection Control, Disaster prevention and last Disaster drill (conducted on 03/24/2025). The LPA obtained Client Roster, and Staff Roster. The LPA reviewed five (5) out of six (6) client files and five (5) out of eleven (11) staff files. Files were reviewed for, but not limited to signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan, personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order at the time of the visit. The LPA and Administrator reviewed P&I Money for all six (6) clients who have their cash resources save guarded by the facility. Cash resources were found to be separate and intact and not commingled with facility funds or petty cash.

Medications: A medication audit was initiated at 10:40 a.m. and the following was observed. The medications were stored in a locked cabinet in the dining room inaccessible to the clients. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

Exit interview conducted and copy of the report and appeal rights provided to the Administrator .

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025

LIC809 (FAS) - (06/04)

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