565850158-1-25-2024-29-AS-KHEN-CZXVT9-20240129154243

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850158
Report Date: 01/25/2024
Date Signed: 01/25/2024 04:48:32 PM

Unsubstantiated

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
01/23/2024 and conducted by Evaluator Kelly Dulek

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20240123211311

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: 55	DATE:	01/25/2024
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Monica Reyes, Executive Director		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Licensee did not provide resident's records as requested

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint investigation for the allegation noted above. LPA met with Executive Director (ED) Monica Reyes at 11:00 a.m. and explained the reason for the visit.

On 1/24/2024, LPA Teresa Camara spoke with the complainant. The complainant confirmed the resident’s records they had requested were received on 1/23/2024 and the concern has been resolved. Therefore, the allegation "Licensee did not provide resident's records as requested" is deemed Unsubstantiated at this time.

No deficiencies observed. Exit interview conducted and report issued to the ED.

Unsubstantiated

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: 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.

LIC9099 (FAS) - (06/04)

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