565850158-11-13-2023-29-AS-KHEN-CYWW3G-20231227155555

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850158
Report Date: 11/13/2023
Date Signed: 11/13/2023 06:02:26 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
11/08/2023 and conducted by Evaluator Kelly Dulek

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20231108105233

FACILITY NAME:	AASTA ASSISTED LIVING		FACILITY NUMBER:	565850158
ADMINISTRATOR:	REYES, MONICA		FACILITY TYPE:	740
ADDRESS:	903 CARMEN DRIVE		TELEPHONE:	(805) 586-4191
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	130	CENSUS: 64	DATE:	11/13/2023
		UNANNOUNCED	TIME BEGAN:	04:08 PM
MET WITH:	Monica Reyes		TIME COMPLETED:	06:05 PM

ALLEGATION(S):

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Licensee issued an unlawful eviction notice to resident in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint investigation for the allegation listed above. LPA arrived at the facility at 04:08PM and met with Executive Director (ED) Monica Reyes. Entrance interview conducted.

During today's visit, LPA interviewed ED at 04:10PM and LPA reviewed and obtained copies of documents pertinent to the investigation. The following was then determined:

On 11/07/2023, LPA Dulek received an email from ED Reyes, which contained an eviction notice for Resident #1 (R1). On 11/08/2023, LPA reviewed the eviction notice and replied to the ED indicating the eviction notice did not contain all the requirements per regulation. LPA requested the ED make changes to the submitted eviction notice and resubmit to CCL for approval. ED acknowledged receipt of the email, however, to date has not sent a revised eviction notice for R1. Interviews revealed that R1 has resided at this location prior to
Report Continued on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20231108105233

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: 11/13/2023

NARRATIVE

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the change of ownership, which occurred on 05/01/2021. R1 had a written agreement under the previous ownership indicating certain terms outside the department approved Admission Agreement. This agreement was made under the previous ownership, and until recently, Aasta had complied with all terms of the previous agreement. Interview revealed that Aasta Administration has had multiple conversations with R1's family member related to obtaining a current Admission Agreement and R1's failure to comply with signing a new agreement is the reason for the eviction notice being issued. ED indicated that the revised letter will contain documentation related to the reasons for the eviction and dates of discussion with R1 and/or their family member. Based on interview and record review, the allegation that "Licensee issued an unlawful eviction notice to resident in care" is deemed SUBSTANTIATED at this time.

The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. ED was informed that 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 Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20231108105233

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: 11/13/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/27/2023 Section Cited HSC 1569.683(a)	1 2 3 4 5 6 7	1569.683 Eviction notices; reasons for eviction contents; service (a) In addition to complying with other applicable regulations...shall set forth in the notice to quit the reasons relied upon for the eviction...quit shall include all of the following: This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Executive Director agreed to rewrite the eviction notice to comply with HSC 1569.683 and will submit the revised copy to CCL by POC due date prior to re-issuing the eviction notice to R1 and/or their family member.
	8 9 10 11 12 13 14	Based on interview and record review, the Licensee did not comply with the above cited section, as an eviction notice was issued for R1, which did not contain reasons for the eviction, nor the required language contained in the above section, which poses a potential personal rights risk to resident 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 Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023

LIC9099 (FAS) - (06/04)

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