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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850158
Report Date: 05/20/2021
Date Signed: 05/20/2021 04:38:08 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: 82DATE:
05/20/2021
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Dylan HullTIME COMPLETED:
04:45 PM
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Licensing Program Analysts (LPAs) Kelly Dulek and Emily Peraldi arrived at this facility to conduct a case management - incident visit for an incident report submitted on 4/21/2021 for Royal Gardens of Camarillo #565801653. Due to the change of ownership on 5/1/2021, the facility address is currently licensed as Aasta Assisted Living. Upon arrival at the facility, LPAs met with Administrator Dylan Hull and identified the reason for the visit as a collateral visit.

During today's visit, LPAs interviewed Administrator Dylan Hull at 3:40PM, interviewed Resident #1 (R1) at 3:09PM and interviewed Staff #1 (S1) at 3:30PM and gathered documents pertinent to the investigation.

The LPAs did not observe any health and safety concerns at the time of the visit.

No deficiencies cited. A copy of the report was issued. Exit interview conducted.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021
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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