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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850158
Report Date: 01/25/2024
Date Signed: 01/25/2024 04:49:30 PM


Document Has Been Signed on 01/25/2024 04:49 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: 55DATE:
01/25/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Monica ReyesTIME COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kelly Dulek conducted a Case Management visit to address deficiencies observed during facility tour and interviews conducted today. LPA met with Executive Director (ED) Monica Reyes. Entrance interview conducted.

During an unrelated visit conducted at the facility today, LPA interviewed staff at 10:10AM, 10:20AM and between 12:26PM to 01:50PM, interviewed ED at 11:02AM, toured the facility with ED at 11:47AM, and LPA reviewed and obtained copies of documents. Interviews revealed that during the overnight shift from 10:00PM to 05:30AM, there were 2 (two) staff present at the facility for 55 residents residing in the facility. The two staff present are responsible for administering medications, checking multiple residents at 15 minute intervals, answering any phone calls and residents' calls for assistance, as well as all assistance with activities of daily living. The facility consists of an Assisted Living (AL) unit and a separate locked Memory Care (MC) unit and there were 2 staff present for the entire building, including both AL and MC. Interviews revealed that on this particular date that a staff had called out and that typically there are 3 staff present during this shift. Interviews revealed there have been previous times there were the same number of staff present, but no dates were clearly identified during today's visit.

The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Administrator 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 HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/25/2024 04:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/01/2024
Section Cited
CCR
87411(a)

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87411 (a) Facility personnel shall at all times be sufficient in numbers....the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.
This requirement is not met as evidenced by:
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Administrator agreed to provide a thorough staffing plan and schedule reflecting sufficient staff coverage, as well as an LIC 500 to include management coverage to CCL by POC due date.
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Based on interview, the licensee did not comply with the above cited section, as during the overnight shift on 01/14-01/15/2024, there were 2 staff present to care for all residents in AL and MC, which poses an immediate health and safety risk to residents 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.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024
LIC809 (FAS) - (06/04)
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