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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850158
Report Date: 07/17/2023
Date Signed: 07/17/2023 06:06:12 PM


Document Has Been Signed on 07/17/2023 06:06 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: 60DATE:
07/17/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Monica ReyesTIME COMPLETED:
06:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kelly Dulek arrived unannounced to conduct a Case Management – Deficiencies visit at this facility. LPA arrived at 10:23AM and met with Administrator Monica Reyes. LPA explained the reason for today's visit. Entrance interview conducted.

Previously, during a visit conducted on 07/07/2023, LPA Dulek had received a copy of the facility's current Admission Agreement. LPA had also previously received and reviewed copies of current residents' Admission Agreements. LPA compared both the copies of residents' Admission Agreements, the blank copy provided on 07/07/2023 and the Admission Agreement that had been submitted with the facility's application and approved at the time of licensure on 05/01/2021. LPA noted the Admission Agreements used with current residents as well the blank copy to be used with new admissions contained discrepancies from the Department approved Admission Agreement.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiency was cited (refer to LIC 809-D). Failure to correct the deficiency may result in civil penalties.

Exit interview conducted with Administrator Monica Reyes. Today's reports 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: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023
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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Document Has Been Signed on 07/17/2023 06:06 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: 07/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/31/2023
Section Cited
CCR
87208(a)

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87208 Plan of Operation (a) Each facility shall have and maintain a current, written definitive plan of operation...changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval...
This requirement is not met as evidenced by:
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The Administrator agreed to discontinue use of the modified Admission Agreement effective immediately. The Licensee will submit to CCL the modified Admission Agreement by POC due date and obtain written approval prior to utilizing the new Admission Agreement and attachments.
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Based on observation and record review, the Licensee did not comply with the above cited section, as the Licensee made changes to the facility's Admission Agreement and did not submit the changes to the Department for approval, which poses a potential personal rights risk to residents in care.
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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: 07/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023
LIC809 (FAS) - (06/04)
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