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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850158
Report Date: 09/26/2024
Date Signed: 10/01/2024 08:17:50 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
08/07/2024 and conducted by Evaluator Valeria Conway
COMPLAINT CONTROL NUMBER: 29-AS-20240807114227
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: 82DATE:
09/26/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Monica ReyesTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff did not give resident medication as prescribed
Staff did not address a change in residents’ condition
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Valeria Conway and Kelly Dulek arrived at the facility unannounced to conduct subsequent complaint visit with the purpose of delivering findings for the allegations listed above. LPA initially met with front desk staff. Executive Director, Monica Reyes, was contacted and arrived at the facility at approximately 10:50 A.M. and explained the reason for the visit. Entrance interview conducted.

On 08/12/2024, from 9:30 A.M. – 3:15 P.M., LPAs initiated an unannounced complaint investigation for the allegations listed above. During the visit, LPAs toured the physical plant, interviewed staff, residents, resident Responsible Party (RP) and reviewed and obtained pertinent documents relevant to the investigation.

It was reported that “Staff did not give resident medication as prescribed” as it was alleged that staff did not obtain the prescribed medication for Resident #1 (R1).

Conitnued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
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-20240807114227
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: AASTA ASSISTED LIVING
FACILITY NUMBER: 565850158
VISIT DATE: 09/26/2024
NARRATIVE
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Continued from LIC 9099

Information gathered during the course of the investigation revealed that R1 resided at this facility from 06/24/2024 to 07/31/2024. On 08/02/2024, R1’s RP noticed a changed in condition and transported R1 to the hospital. The Centrally Stored Medication and Destruction Record (CSMDR) for R1 obtained and reviewed, reflected that R1 was prescribed Olanzapine once a day beginning in May 2024; however, the “Date Started” column was left incomplete by the facility as of 08/12/2024. Interview with Resident Care Coordinator revealed that the facility only assists with self-administration of medications based on the medication list signed by the physician and not what a resident brings during admission. LPAs reviewed R1 facility file and did not find a list of medication signed by any physician. Furthermore, LPAs requested Resident Care Coordinator and Med-Tech to provide a copy of the list of medication signed by R1’s physician, however neither the Resident Care Coordinator nor the Med-Tech on duty were able provide such document. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that R1 was not assisted with self-administration of medication. Therefore, the above allegation “Staff did not give resident medication as prescribed” is deemed SUBSTANTIATED at this time.

It was also alleged that staff did not address a change in residents’ condition. It was reported R1’s Private Caregiver noticed blood in R1s underwear on 07/15/2024 and on 07/19/2024; however, the facility did not make any efforts to obtain any medical attention for R1 even after being notified. Information gathered reflected that R1's PC observed blood on R1’s underwear on 07/15/2024 and notified both the facility staff and R1’s RP. Additionally, R1 was also displaying mood changes such as agitation and distress. However, there is no documentation to support that the facility contacted R1’s Primary Care Physician (PCP) or attempted to obtain R1 any medical services. On 07/19/2024, after observing blood in R1’s underwear again, R1’s RP contacted Kaiser and R1 was diagnosed with a Urinary Tract Infection (UTI).

Continued on LIC 9099-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20240807114227
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: AASTA ASSISTED LIVING
FACILITY NUMBER: 565850158
VISIT DATE: 09/26/2024
NARRATIVE
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Continued from LIC 9099-C

LPAs interview with administrator revealed that administrator could not recall the incident occurring. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation that “Staff did not address a change in residents’ condition” has been SUBSTANTIATED at this time.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 9099-D). Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted, appeal rights discussed, and a copy of report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
08/07/2024 and conducted by Evaluator Valeria Conway
COMPLAINT CONTROL NUMBER: 29-AS-20240807114227

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: 82DATE:
09/26/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Monica ReyesTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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2
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9
Staff did not safeguard resident's personal items
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Valeria Conway and Kelly Dulek arrived at the facility unannounced to conduct subsequent complaint visit with the purpose of delivering findings for the allegations listed above. LPA initially met with front desk staff. Executive Director, Monica Reyes, was contacted and arrived at the facility at approximately 10:50 A.M. and explained the reason for the visit. Entrance interview conducted.

On 08/12/2024, from 9:30 A.M. – 3:15 P.M., LPAs initiated an unannounced complaint investigation for the allegations listed above. During the visit, LPAs toured the physical plant, interviewed staff, residents, resident Responsible Party (RP) and reviewed and obtained pertinent documents relevant to the investigation.

Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20240807114227
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: AASTA ASSISTED LIVING
FACILITY NUMBER: 565850158
VISIT DATE: 09/26/2024
NARRATIVE
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Continued from LIC 9099

It was reported that "Staff did not safeguard residents' personal items". The RP's concern is that R1’s personal items have gone missing from their room. A file review revealed that the Client/Resident Personal Property and Valuables form (LIC621) which is use to itemize R1’s personal belongings, did not list the missing item. Furthermore, R1 never notified and/or divulged information to facility management and/or staff about updating or adding items to R1's LIC 621 since being admitted to the facility. As a result, there is no documented record of what personal property may have been present in R1’s room during the time of the alleged loss. Interview with staff revealed that staff will follow protocol, notifying the administrator immediately. Interviews with the administrator indicates that staff, residents, and sometimes responsible parties, do inform if an item goes missing. When this occurs, the staff will assist in searching for the missing item(s).

Although the allegation may have happened or is valid, based on the interviews there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

No citation issued. Exit interview conducted, and a copy of report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20240807114227
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AASTA ASSISTED LIVING
FACILITY NUMBER: 565850158
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2024
Section Cited
CCR
87465(a)(4)
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 87465 (a)(4) Incidental Medical and Dental Care. (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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Licensee will review requirements of this section and provide a written statement outlining their understanding of the requirements to CCL by POC due date
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Based on record review and interviews, the licensee did not comply with the section cited above as medications are not being given to R1 which posed an immediate health and safety concern to persons in care.
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Type B
10/10/2024
Section Cited
CCR
87466
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87466The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional...When changes such as unusual...physical health condition...responsible person, if any. This requirement was not met as evidenced by:
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Administrator stated that she will submit a plan on how to ensure staff monitor residents for any change in condition and ensure that arrangement of medical care is proper and submit a plan of staff training regarding above regulation. Submit to CCL before POC due date.
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Based on interviews, and records review
Licensee/Administrator did not obtain timely medical attention for R1 which posed an immediate health and safety concern to persons 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.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6