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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850158
Report Date: 04/27/2021
Date Signed: 04/27/2021 06:26:49 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:AASTA ASSISTED LIVINGFACILITY NUMBER:
565850158
ADMINISTRATOR:HULL, DYLANFACILITY TYPE:
740
ADDRESS:903 CARMEN DRIVETELEPHONE:
(818) 317-9565
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:130CENSUS: 83DATE:
04/27/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:16 AM
MET WITH:Nandini Kumar, Narinder Kumar, Dylan HullTIME COMPLETED:
06:25 PM
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Licensing Program Analyst (LPA) Kelly Dulek conducted a pre-licensing visit to this property at 9:16am. This is a change of ownership application. LPA met with applicant representatives Narinder and Nandini Kumar, Aasta employee Jamie Kidwell, consultant Anna Fabregas, property owner Boris Chernega, Royal Gardens licensee Thomas Ayer, and Administrator Dylan Hull. The applicant has obtained fire clearance for one hundred ten (110) non-ambulatory and twenty (20) bedridden (in rooms 101-114) for a total capacity of one hundred thirty (130) clients. During today’s visit, component III was also completed with licensee representatives Jamie Kidwell and Nandini Kumar. Applicant also completed component II interview on 4/14/2021.

Beginning at 9:25AM, LPA inspected the proposed facility for Fire Safety, Personal Accommodations, and Food Service. All hard-wired smoke alarms and carbon monoxide detectors as well as fire doors were tested during the fire inspection on 4/2/2021. LPA observed fire extinguishers throughout the building to be fully charged and last serviced 2/16/2021. Administrator stated there are no firearms on the premises. Indoor common areas consisting of the lobby, library, Garden Room, Activity Room, dining room, Bistro, private dining room and movie room in the Assisted Living side and Activity Room and dining room in Memory Care are clean and properly furnished. A working telephone is present.

The facility has 107 bedrooms total – 24 in memory care and 83 in Assisted Living. LPA checked a sampling of 8 resident rooms throughout the facility. All observed resident bedrooms were furnished and contained beds, chairs, bedside tables and lamps. All beds have sheets, pillows, and mattress pads. There is also an ample supply of linen, towels and paper products. Hot water was measured in all 8 resident rooms. Temperature readings were inconsistent throughout the facility, measuring between 98.2 degrees Fahrenheit and 114.0 degrees Fahrenheit. In one resident room, the temperature read 92 degrees Fahrenheit initially, rose and remained at 95.2 degrees Fahrenheit, then after approximately 10 minutes rose to 114.2 degrees Fahrenheit. During a subsequent walk through at 3:25PM, water temperatures were still inconsistent in 3
Report Continued on LIC 809-C
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: AASTA ASSISTED LIVING
FACILITY NUMBER: 565850158
VISIT DATE: 04/27/2021
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resident rooms. However, before leaving the facility, LPA measured the temperatures to be within the required range of 105 to 120 degrees Fahrenheit in the 3 resident rooms.

At 9:26AM, LPA Dulek and Administrator Hull observed unlocked cabinets containing Spic and Span cleaner, Critical Care cleaner, Febreze spray, and Ajax cleaner in the common area in the Memory Care unit. 3 cabinets in total were observed unlocked. 2 resident restrooms in the Memory Care unit were observed dirty at 9:36AM and 9:40AM. At 9:36AM, in an unlocked Memory Care room, a razor and nail clippers were observed. During a subsequent facility walk through at 3:25 PM, LPA observed both restrooms had been cleaned, cabinets were observed to be locked and the personal items had been moved to a locked location. At 9:30AM, LPA observed the delayed egress at the end of the Memory Care hallway leading to the outside patio is not functioning properly. There is an additional delayed egress upon exiting the Memory Care patio, which was tested and functional at the time of the visit. Administrator Hull called and spoke with Fire Inspector Richard Martinez at approximately 3:00PM, who indicated that while ideally the delayed egress at the end of the hall is fixed, there is not an imminent danger to residents because the door opens as long as the delayed egress on the outside patio is functional.

The kitchen contained a sufficient supply of dishes, glasses and utensils. A seven-day supply of non-perishable food and three-day supply of perishable food is present. food delivery was received during today’s visit. Initially, produce boxes were observed stored on the ground, but LPA verified all boxes were moved during the visit. Chemicals are stored in a closet in the back of the kitchen, separate from the food storage area. Dining room was observed to have gaps in the floorboards, and a broken threshold, causing a safety hazard. During the subsequent walk through at 3:25PM, LPA observed a new threshold had been installed and the floorboards had been adjusted to limit the gaps.

The locked medication room is located in the Assisted Living side of the facility. Medications were reviewed at 4:00PM. All three (3) resident medications and records reviewed were in compliance with regulation at the time of the visit. The first aid kit is located in the medication room and was observed to be complete at this time. Facility laundry room is located next to the activity room. All supplies are locked in the laundry room.

Building and grounds were observed throughout today’s visit. Patio area observed with table and chairs and shaded seating areas for resident use. Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: AASTA ASSISTED LIVING
FACILITY NUMBER: 565850158
VISIT DATE: 04/27/2021
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There is a water fountain present in front of the facility, but residents do not have access to this area, as it is outside the front entry.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted and report issued via email.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3