<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850158
Report Date: 07/17/2023
Date Signed: 07/17/2023 06:04:11 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/25/2023 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20230125094625
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
UNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Monica ReyesTIME COMPLETED:
06:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not ensure resident's blood sugars were being monitored properly while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a subsequent complaint inspection for the allegation listed above at 10:23AM. The LPA met with Administrator Monica Reyes and explained the reason for today's visit. Entrance interview conducted.

During today's visit, LPA interviewed staff at 11:20AM, conducted staff and resident interviews between 01:05PM and 03:21PM. During an initial complaint inspection at the facility on 01/26/2023, LPA interviewed Administrator at 01:30PM and at various times throughout the visit, LPA toured the facility with Administrator at 01:50PM, and gathered copies of pertinent documents. Throughout the course of the investigation, LPA reviewed pertinent documents and interviewed residents related to this complaint during unrelated facility visits. The following was then determined:

Report Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 29-AS-20230125094625
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/17/2023
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
26
27
28
29
30
31
32
Allegation: “Facility staff did not ensure that resident's blood sugars were being monitored properly while in care:”

Resident #1 (R1) had high blood sugar and A1C levels and reporting party was concerned that R1’s blood sugars were not properly being monitored. LPA reviewed physician’s orders and documents obtained at the facility. Interview with R1 revealed the facility staff check R1’s blood sugar by helping R1 to poke their finger and measure blood sugar. However, R1 could not recall how long the facility has been assisting with measuring their blood sugar level. Physician’s orders dated 10/05/2022 indicate orders for “Accucheck am and record.” Med room staff sent a fax to R1’s physician on 10/10/2022 asking to “clarify the following orders. Pharmacy was unable to read.” Date stamp for return fax from R1’s physician was cut off, so LPA was unable to identify when the response was received. The faxed document was provided to the LPA during the 01/26/2023 visit, so it is clear that by the time of the visit, the facility had received the document, yet R1’s blood sugars were not monitored or recorded. Interviews revealed that the facility staff were unaware of the 10/05/2022 doctor’s orders or the 10/10/2022 clarification of doctor’s orders and indicated it wasn’t until February that R1’s physician wrote an order for R1’s blood sugar to be monitored. On 02/08/2023, med room staff sent a request to R1’s physician for a blood sugar check twice a day, per R1’s request. R1’s physician replied the same day and indicated to “check blood sugar (before breakfast, before dinner) daily and notify” physician within parameters given. Record review revealed that the facility staff began assisting R1 in checking their blood sugar beginning on 02/09/2023. However, record review revealed that the original doctor’s orders for Accucheck were written on 10/05/2022 and were not followed. Therefore, based on record review and interview, there is sufficient evidence to support the allegation and the allegation that “facility staff did not ensure that resident’s blood sugars were being monitored properly while in care” is deemed SUBSTANTIATED at this time.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiency was cited (refer to LIC 9099-D). Failure to correct the deficiency 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: 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
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/25/2023 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20230125094625

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
UNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Monica ReyesTIME COMPLETED:
06:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not ensure that resident received medication while in care
Facility staff did not ensure that resident had a change of clean clothing while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a subsequent complaint inspection for the allegations listed above at 10:23AM. The LPA met with Administrator Monica Reyes and explained the reason for today's visit. Entrance interview conducted.

During today's visit, LPA interviewed staff at 11:20AM, conducted staff and resident interviews between 01:05PM and 03:21PM. During an initial complaint inspection at the facility on 01/26/2023, LPA interviewed Administrator at 01:30PM and at various times throughout the visit, LPA toured the facility with Administrator at 01:50PM, and gathered copies of pertinent documents. Throughout the course of the investigation, LPA reviewed pertinent documents and interviewed residents related to this complaint during unrelated facility visits. The following was then determined:

Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20230125094625
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/17/2023
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
26
27
28
29
30
31
32
Allegation: “Facility staff did not ensure that resident received medication while in care:”

The complaint alleges that facility staff did not ensure R1 received their diabetes medications, resulting in high blood sugar and A1C levels. Physician’s report indicates R1 can administer their own insulin pen with assistance. Interview with R1 revealed that facility staff regularly assist R1 with their diabetes medications, throughout the day as ordered by R1’s physician. Staff interviewed indicated that the medication technician sets up the insulin pen with the proper amount of insulin. Staff stated R1 is cooperative with medications, but sometimes, R1 requires hand-over-hand assistance for their diabetes care. LPA reviewed medication logs for R1 during the time of the complaint allegation. Medication logs indicate R1 received all 3 (three) injectable medications related to diabetic care as prescribed during the month of the complaint allegation. Interview with R1 revealed that the staff do assist R1 with medications and that the medication technicians come into R1’s room to administer injectable medications four (4) times daily. Staff interviews revealed that medications are administered and initialed either in the electronic MAR or paper MAR as appropriate for each resident. Based on record review and interview, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “facility staff did not ensure that resident received medication while in care” is deemed UNSUBSTANTIATED at this time.

Allegation: “Facility staff did not ensure that resident had a change of clean clothing while in care:”

LPA reviewed the care assessment and service plan dated 10/25/2022 and labeled updated care plan for R1. Care plan indicates R1 is independent in dressing. Physician’s report dated 05/17/2022 indicates R1 requires supervision with grooming and hygiene needs, but is independent for dressing. During an unrelated visit on 06/13/2023, LPA interviewed R1 at 04:58PM. R1 indicated they pick out their own clothing and dress themselves. Laundry is washed twice weekly; it is taken on the resident’s designated laundry day and is delivered back to the resident’s room the same day by the housekeeping staff. LPA observed that all of R1’s clothing was clean, including what R1 was wearing during the visit. Staff interviews revealed that R1 is relatively independent, picks out their own clothes, and dresses themselves independently. Therefore, based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation; as thus, the allegation that “facility staff did not ensure that resident had a change of clean clothing while in care” is deemed UNSUBSTANTIATED at this time.

No citations issued in relation to the above allegations. Exit interview conducted with Administrator. A copy of the report was 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
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20230125094625
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 A
07/21/2023
Section Cited
CCR
87628(a)
1
2
3
4
5
6
7
87628 Diabetes (a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication...skilled professional.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator agreed to conduct an inservice on section 87628 Diabetes for all medication technicians and provide proof of training to CCL by POC due date.
8
9
10
11
12
13
14
Based on interview and record review, the Licensee did not comply with the above cited section, as R1's physician ordered blood glucose testing on 10/05/2022 and the facility staff was unaware of the orders and R1's need for medical assistance, which posed an immediate health risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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
LIC9099 (FAS) - (06/04)
Page: 6 of 6