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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850158
Report Date: 08/30/2023
Date Signed: 08/30/2023 01:20:46 PM


Document Has Been Signed on 08/30/2023 01:20 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: 59DATE:
08/30/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Monica ReyesTIME COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Kelly Dulek initiated a Case Management visit today with the purpose of confirming the removal of Individual #1 (I1) from the facility. LPA arrived at 09:52AM and met with Wellness Director Esmeralda Elizarraraz at 10:00AM. Administrator was contacted via telephone and arrived at 12:50PM. Entrance interview conducted.

The Woodland Hills Regional Office (RO) received a Default Decision and Order with an effective date of 09/08/2023, indicating that I1, who had sought employment with the facility, is prohibited from employment in any facility licensed by the Department. Prior to today's visit, LPA reviewed the facility's Guardian roster to ensure I1 is not associated to the facility. During today's visit, LPA interviewed Wellness Director at 10:00AM and confirmed that I1 never worked, trained, or interacted with any residents in the facility. I1 was a prospective employee, but did not obtain background clearance, therefore, the facility did not hire I1. LPA did not observe I1 in the facility during the visit. The facility Management is aware that I1 cannot be hired or present in the facility.

No citations issued. Exit interview conducted. A copy of today's report was provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023
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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