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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850158
Report Date: 04/12/2023
Date Signed: 04/12/2023 07:04:23 PM


Document Has Been Signed on 04/12/2023 07:04 PM - It Cannot Be Edited

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:REYES, MONICAFACILITY TYPE:
740
ADDRESS:903 CARMEN DRIVETELEPHONE:
(805) 586-4191
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:130CENSUS: 57DATE:
04/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Monica ReyesTIME COMPLETED:
07:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Kelly Dulek and Emily Peraldi arrived at the facility unannounced to conduct a required annual visit at 09:13AM. LPAs were greeted by facility staff and initially met with Esmeralda Elizarraraz and explained the reason for today’s visit. Administrator Monica Reyes arrived shortly thereafter. Entrance interview conducted.

Beginning at 09:44AM, the LPAs, along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

BEDROOMS: The facility consists of 107 total bedrooms, of which LPAs observed 10 resident bedrooms; 2 in the Meadows (Memory Care) and 8 in Assisted Living. All resident rooms observed were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. At 09:52AM, in Resident #1 (R1)’s room LPAs observed the following: Mucus DM Extended Release, Vicks VapoRub, Beta Prostate Max, Calmoseptine, A&D Ointment, Remedy Phytoplex Clear-Aid Ointment and other various medications.

RESTROOMS: Each resident room contains its own private restroom. Resident restrooms observed contained sufficient grab bars and non-skid surfaces. At 10:02AM, in Room 415, water temperature measured at 126.7 degrees Fahrenheit. At 10:08AM, in Room 403, water temperature measured at 124.1 degrees Fahrenheit.

COMMON AREAS: Consisting of the lobby, library, activity room, dining room, bistro, and movie room in the Assisted Living side and activity room and dining room in the Meadows side. The LPAs observed common areas to be relatively clean and properly furnished at the time of the visit. The LPAs observed the fire extinguishers to be fully charged and last serviced on 02/08/2023. All hardwired smoke alarms as well as
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: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: AASTA ASSISTED LIVING
FACILITY NUMBER: 565850158
VISIT DATE: 04/12/2023
NARRATIVE
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fire doors and sprinkler system were inspected during the fire inspection which took place on 05/18/2022 and were functional at that time. During today’s visit, at 04:36PM, carbon monoxide detectors were tested and functioned properly. The temperature was maintained at a comfortable level throughout the building. Cleaning supplies and disinfectants are stored locked per regulation. The LPAs observed cameras in the common areas. A working telephone is present. The LPAs observed the required postings in the common area.

OUTDOOR SPACE: At 10:37AM, the LPAs observed the building and grounds in both Assisted Living and Memory Care. Multiple seating areas were observed with tables and chairs and shaded seating areas for resident use.

RECORD REVIEW: Began at 11:12AM, LPAs reviewed staff and resident records for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisals, and admission agreements. 5 of 5 staff files reviewed contained all documents, except documentation of required initial and annual training. Administrator indicated staff have completed all required training but was unable to access the records due to the internet not functioning at this time. 5 resident files were reviewed. 2 of 5 resident files reviewed did not contain a current reappraisal, however current appraisals were completed during today’s visit. Remaining files reviewed were observed to be in compliance.

MEDICATION REVIEW: Began at 01:28PM. Medications for 5 residents were reviewed. At 01:30PM, Resident #2 (R2)’s medication Multaq 400mg was observed. PM dose was not initialed as administered on the April Medication Administration Record (MAR) at all, however 11 pills were not remaining in the bubble pack and bubble pack was started on 04/01/2023. At 01:39PM, Resident #3 (R3)’s medication Vitamin B-12 100mg, which is ordered weekly on Mondays. Start date is indicated as 04/01/2023 and the package originally contained 5 pills. 2 pills remain in the bubble pack, however only 2 Mondays have passed in April. At 01:49PM, LPAs observed Resident #4 (R4)’s medication Hydrocodone APAP 10-325. Bubble pack originally contained 30 doses of 2 pills each. 12 doses remain in the bubble pack and the start date is listed as 04/09/2023. MAR reviewed indicated 14 doses have been administered since 04/09/2023, leaving 4 doses of 2 pills each unaccounted for. At 01:51PM, R4’s Metformin HCL 1000mg was observed. 2 bubble packs
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: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/12/2023 07:04 PM - 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: AASTA ASSISTED LIVING
FACILITY NUMBER: 565850158

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as 4 of 5 resident medications reviewed contained inconsistencies with their medication amounts remaining and amounts documented as administered on the MAR which poses an immediate health and safety risk to persons in care.
POC Due Date: 04/19/2023
Plan of Correction
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Administrator agreed to do a complete medication audit for the facility and training for all medication staff and submit documentation to CCL by POC due date.
Type A
Section Cited
CCR
87465(h)(1)(C)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (C) Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, the medications are determined by either a physician, the administrator, or Department to be a safety hazard to others.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as 2 of 5 residents observed had medications stored in their rooms, however physician's report indicated residents are not able to store their own medications which poses an immediate health and safety risk to persons in care.
POC Due Date: 04/14/2023
Plan of Correction
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Administrator agreed to move all medications out of the 2 resident rooms and contact the residents' physicians to clarify medication storage requirements for these residents and to provide proof to CCL by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023
LIC809 (FAS) - (06/04)
Page: 3 of 13


Document Has Been Signed on 04/12/2023 07:04 PM - 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: AASTA ASSISTED LIVING
FACILITY NUMBER: 565850158

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Diabetes
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Type A
Section Cited
CCR
87705(c)(4)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as during facility tour, there was only one caregiving staff working in the Memory Care unit to supervise 18 residents, one of which was wandering and attempting to exit which poses an immediate health, safety, and personal rights risk to persons in care.
POC Due Date: 04/12/2023
Plan of Correction
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During the visit, Administrator called another staff to assist in Memory Care until the 2nd caregiver returned from lunch. Administrator agreed to submit to CCL by 04/19/2023 a plan for staffing coverage during lunch breaks.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023
LIC809 (FAS) - (06/04)
Page: 4 of 13


Document Has Been Signed on 04/12/2023 07:04 PM - 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: AASTA ASSISTED LIVING
FACILITY NUMBER: 565850158

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the bottom drawer in the Memory Care kitchen containing items such as lotions, incontinence care products, and nail polish remover was observed open and unable to be locked, which poses an immediate health and safety risk to persons in care
POC Due Date: 04/12/2023
Plan of Correction
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Items were secured in a locked cabinet during today's visit. POC cleared.
Type A
Section Cited
CCR
87303(e)(2)
87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 10 resident rooms observed had a water temperature reading at 124.1 degrees Fahrenheit and 126.7 degrees Fahrenheit which poses an immediate safety risk to persons in care.
POC Due Date: 04/19/2023
Plan of Correction
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Water temperature was adjusted during today's visit. Administrator agreed to record water temperatures in randomly selected rooms for a 7 day period at various times of the day on a log and submit the log to CCL by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023
LIC809 (FAS) - (06/04)
Page: 5 of 13


Document Has Been Signed on 04/12/2023 07:04 PM - 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: AASTA ASSISTED LIVING
FACILITY NUMBER: 565850158

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as LPA observed multiple canned items which were expired, as well as tofu in the refrigerator was expired, which poses a potential health risk to persons in care.
POC Due Date: 04/19/2023
Plan of Correction
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Administrator asked kitchen staff to throw away all items identified during today's visit. Additionally, Administrator agreed to complete a full audit of all pantry, refrigerator, and freezer items and emergency food items by POC due date.
Type B
Section Cited
CCR
87625(b)(3)
Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as one vacant room and 2 facility hallways were observed to be malodorous which poses a potential personal rights risk to persons in care.
POC Due Date: 04/26/2023
Plan of Correction
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Administrator agreed to ensure the room is cleaned and all facility hallways are cleaned and remain odor free. Proof of cleaning to be provided to CCL by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023
LIC809 (FAS) - (06/04)
Page: 6 of 13


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: 04/12/2023
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originally contained 60 doses. Each bubble pack has 18 remaining doses, however MAR indicates 23 doses have been administered, leaving one dose unaccounted for. At 02:09PM, R1’s pm medication Melatonin 5mg was observed, which originally contained 30 doses, start date is listed as 03/23/2023. 20 days have elapsed since the listed start date. Therefore, 10 doses should remain, however LPAs observed 8 remaining doses in the bubble pack.

KITCHEN: At 03:32PM, LPA Dulek observed the kitchen/dining area. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food, including emergency supply. At 03:34PM, LPA observed 12 cans of Annie’s Cheesy Ravioli with a best by date of 09/04/2022. At 03:35PM, LPA observed 4 cans of Hunts Tomato Paste with a best by date of 02/27/2023. At 03:35PM, LPA observed 4 cans of Siniora Chicken Luncheon Meat with a sell by date of 02/25/2021. At 03:37PM, LPA observed 3 cans of condensed milk with a best by date of 10/22/2022. At 03:42PM, LPA observed 2 packages of tofu in the refrigerator with a use by date of 03/30/2023.

INFECTION CONTROL: During today’s visit, the LPAs spoke with the Administrator regarding the facility’s infection control practices. The facility’s policies and procedures as it pertains to infection control are adequate.

INTERVIEWS: Throughout today’s visit, LPAs interviewed 4 (four) staff and 4 (four) residents.

The following deficiencies were 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 deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

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

DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023
LIC809 (FAS) - (06/04)
Page: 13 of 13