Ashley's Manor I

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct the required annual visit at 9:15 A.M. The LPA initially met with caregiver Calixto “Alex” Calixtro and staff Eufrecina Tabuena. Licensee, Maricar Lee was contacted via telephone. At 10:10 A.M. facility designee, Michelle Viernes, arrived at the facility. Licensee arrived at 11:20 A.M. Entrance interview was conducted. Beginning at 10:20 A.M., the LPA along with facility designee toured the physical plant areas inside and outside 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 were observed to be in good condition. The LPA observed the required postings in the common areas. 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 temperature of 72 degrees. LPA observed a working phone available for residents use whenever needed. Fire extinguisher was observed to be fully charged and last serviced 07/18/2025. LPA observed that fire extinguisher was mounted on the far wall of the common/TV area. Recliners, wheelchairs and other items were positioned in front of and around the extinguisher, obstructing direct access. LPA requested to relocate the fire extinguisher to a readily accessible location. Hardwired combination of carbon monoxide and smoke detectors and a fire door were tested at 10:46 A.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. Continued on LIC 809-C Continued from LIC 809-C 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. BATHROOMS: Three (3) bathrooms 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 bathrooms and private bathroom 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 10:55 A.M. and measured 111.5 degrees Fahrenheit. OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for residents’ use. There was a three-tier water fountain and a bird bath fountain noted. A small amount of standing water was present in both fountains due to rainfall from the previous day. During today’s visit, LPA requested that staff immediately dry out and empty both fountains. Facility has two (2) total side gates; both were observed to be self-closing and self-latching gates, however, during today’s visit the side gate located adjacent to the garage was observed to be secured with a metal wire, obstructing the gate from opening. LPA observed a clear passageways for emergency exit use. Facility provides sufficient space to accommodate both indoor and outdoor activities. GARAGE: The Garage remains locked and inaccessible to the residents in care. There’s an area for the washer and dryer machine. Cleaning and laundry supplies were locked and properly storage inside a locked cabinet. A separate pantry with emergency supply was observed. Additionally, LPA observed a sufficient amount of emergency water. Continued on LIC 809-C Continued on LIC 809-C RECORD REVIEW: Between 11:30 A.M. and 1:05 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. Five (5) resident records were reviewed. LPA observed that Resident #1 (R1) and Resident #2 (R2) have no capacity for self-care and they are not receiving hospice services. The LPA informed the licensee and designee that the facility needs to have an approved exception with the department for each resident that requires full care and is not on hospice. Additionally, LPA observed that four (4) out of five (5) residents did not have a signed needs and service plan form. Six (6) staff files reviewed were complete and contained all required documents. MEDICATION REVIEW: Began at 1:15 P.M. Medications for five (5) 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. 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. LPA did not observe any discrepancies during today’s visit. LPA obtained the following documents during today’s visit; Personnel Record (LIC500), Resident Roster (LIC9020A), current Liability Insurance, and infection control policy as well as the emergency disaster plan. Infection control and disaster plan forms were updated yearly as required by regulation. Last emergency disaster drill was conducted on 1/25/2026. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. An immediate civil penalty of $500 was issued. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 12, 2026

Type of visit: Case Management - Annual Continuation

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 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.the state’s words, verbatim · CDSS document, Jan 29, 2025

Type of visit: Required - 1 Year

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 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 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.the state’s words, verbatim · CDSS document, Jan 28, 2025

Allegation investigated: Facility is not kept free of rodents

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 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.the state’s words, verbatim · CDSS document, Mar 13, 2024 · control 29-AS-20240308161112

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Mar 20, 2024

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: 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.the state’s words, verbatim · CDSS document, Mar 13, 2024

Plan of correction: Licensee indicated pest control services will be provided tomorrow and upon completion, Licensee will provide proof to CCL by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 10:23AM. The LPA initially met with staff Eufrecina Tabuena. Licensee and facility Designees were contacted. Facility Designee arrived at 10:28AM, the Licensee Maricar Lee and other facility designee arrived shortly after the visit began. Entrance interview conducted. The LPA, along with Facility Designee, toured the physical plant areas inside and outside at 10:45AM to ensure there are no health and safety hazards and the facility is in compliance with Title 22 regulation. The following was observed: Fire extinguisher was observed to be fully charged and last serviced 07/17/2023. Hardwired combination carbon monoxide and smoke detectors and fire door were tested at 02:15PM and all were functional at the time of the visit. 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. 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, but both did contain some standing water. Facility designee noted water had accumulated during the recent rains. Licensee drained/removed water from both fountains during today's visit. At 10:45M and 10:49AM, respectively, both outdoor gates were observed to not fully open and not self-close nor self-latch. The garage was observed locked and contained locked storage cabinet for laundry supplies and separate food supply, as well as laundry area, and extra storage. Report Continued on LIC 809 - C 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: 3 restrooms were observed to be clean and sanitary and in operating condition. Showers were also observed to have grab bars and non-skid 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. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. RECORD REVIEW: LPA reviewed 5 (five) resident files and 5 (five) staff files for documents including but not limited to physician's report, Admission Agreement, needs and service appraisal, personal rights, fingerprint background clearance, TB test, and staff training records. All files reviewed contained all required documents. MEDICATION REVIEW: LPA reviewed medications for 2 (two) residents. Both 2 (two) of 2 (two) were observed to be properly stored, documented, and contained no discrepancies. INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPA reviewed the facility's infection control plan. The facility's procedures relating to infection control are adequate. LPA also reviewed the facility's emergency disaster plan, which was completed and updated annually as required. Emergency disaster drills are conducted every 3 (three) months, with the last documented drill conducted in February 2024. INTERVIEWS: During today's visit, LPA interviewed 2 (two) staff and 2 (two) residents. The following deficiency was observed (See LIC 809-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.the state’s words, verbatim · CDSS document, Mar 13, 2024