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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850158
Report Date: 11/25/2024
Date Signed: 11/25/2024 03:45:58 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
01/02/2024 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 29-AS-20240102113855
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: 78DATE:
11/25/2024
UNANNOUNCEDTIME BEGAN:
01:56 PM
MET WITH:Monica Reyes, Executive DirectorTIME COMPLETED:
03:48 PM
ALLEGATION(S):
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Neglect/lack of supervision leading to questionable death
Neglect/lack of supervision: facility employees failed to properly supervise resident resulting in an unwitnessed fall and injuries to the resident
Licensee did not meet resident’s ADL needs
Licensee did not provide resident’s responsible party an updated care plan
Licensee did not comply with reporting requirements
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Kelly Dulek and Emily Peraldi conducted a subsequent complaint investigation with the purpose of delivering findings for the allegations listed above. LPA arrived at the facility at 01:56PM and initially met with facility staff. LPA met with Executive Director (ED) Monica Reyes at 02:00PM. Entrance interview conducted.

During an initial complaint visit conducted on 01/04/2024, LPA interviewed staff at 11:43AM, 01:09PM, and 01:25PM, interviewed ED at 11:55AM, toured the facility with ED at 12:15PM, and LPA reviewed and obtained copies of documents pertinent to the investigation. No immediate health and safety concerns were identified during that facility tour. ED was informed that the allegations were referred to Community Care Licensing Division (CCLD)’s Investigation Branch (IB). IB Investigator Douglas Real obtained copies of Resident #1 (R1)’s medical records, interviewed staff, residents and other relevant parties both telephonically or in person on the following dates: 01/22/2024, 01/31/2024, 02/13/2024, and attempted
Report Continued on LIC 9099-C (p. 2)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
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 8
Control Number 29-AS-20240102113855
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: 11/25/2024
NARRATIVE
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interviews on 02/27/2024, 03/15/2024, and 03/25/2024. Throughout the course of the investigation, LPA, IB Investigator and CCLD’s Program Clinical Consultant reviewed relevant documents for R1, including medical documents. A summary of documents reviewed and interviews conducted is as follows:

Review of documents for R1 revealed that R1 had resided at this location since 12/31/2011 (formerly licensed as Royal Gardens of Camarillo). Physician’s reports were reviewed for the years 2020, 2021 and 2023. Physician’s report dated 06/17/2020 indicated “fall risk, [R1] recently moved to secure memory care unit on 06/16/2020 for close monitoring.” Physician’s report dated 03/24/2021 indicated R1 had motor impairment/paralysis, with a comment indicating “unsteady gait.” Physician’s report dated 03/09/2023 indicated R1 had a motor impairment/paralysis and assistive device was listed as walker, wheelchair. All physicians’ reports dated 2020 to present indicate R1 had a diagnosis of dementia and R1 required assistance with all activities of daily living except assistance with feeding.

IB investigator requested copies of all incident reports related to R1 during the time they resided at the facility, however Administrator only provided 1 (one) report indicating R1 had previously fallen. Review of incident reports submitted to CCLD revealed an additional 2 (two) falls R1 sustained at the facility since operating as Aasta Assisted Living. Interviews with staff also revealed that R1 was “definitely becoming a fall risk” at the time of the incident on 12/28/2023. Incident report related to this complaint states that R1 was last checked on in their room at 6:00AM, when care staff assisted R1 with getting dressed. “Care staff went to [R1’s] room to remind [R1] it was breakfast time. When Ana walked in she saw [R1] laying face down in the middle of the room, she noticed blood on [R1’s] head and called medtech.” After interviews and document review, the following was then determined:

Allegations: Neglect/Lack of supervision leading to questionable death & Neglect/Lack of supervision: facility employees failed to properly supervise resident resulting in an unwitnessed fall and multiple injuries to the resident:


The complaint alleges the facility employees failed to provide an appropriate level of supervision, which resulted in R1 falling, hitting their head causing periorbital fractures as well as a brain hemorrhage. Complaint alleges R1 died in the hospital several days later as a result of the injuries sustained in the fall. Incident report reviewed indicated staff found R1 on the floor of their room around 06:30AM on 12/28/2023. Internal incident report indicates R1 had last been observed by staff at 06:00AM, when care staff assisted R1 Report Continued on LIC 9099-C (p.3)
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 29-AS-20240102113855
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: 11/25/2024
NARRATIVE
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with dressing. Interview revealed that both documents were originally authored by staff that had initially found R1 after the fall and included additional details, but were rewritten inaccurately by another staff. LPA observed that the incident report indicates R1’s right side of their face was affected, however hospital documents indicate injuries were sustained on R1’s left side. Interview revealed that although R1’s annual physician’s reports and care assessments indicated R1 required a full assist with all personal grooming and hygiene needs, care staff reported regularly leaving R1 in their room unsupervised to brush their own hair and wash their own face. Additionally, physician’s report dated 03/24/2021 indicated R1 is “at risk if allowed direct access to personal grooming and hygiene items” yet care staff allowed R1 access to said items unsupervised to complete their own ADL care. Staff interviews revealed that as expected as R1 was aging and due to R1’s overall medical condition including their diagnosis of dementia, R1 was becoming less capable of completing tasks independently and R1 regularly forgot to use their walker, which made R1 a fall risk. In spite of documentation on both R1’s care assessment and R1’s physician’s reports indicating R1 requires a full assist with ADL care (except feeding,) on 12/28/2023, care staff left R1 in their room to complete personal hygiene and grooming tasks without any required staff assistance or supervision. Additionally, staff interviewed were aware R1 did require transfer assistance “at times” and that R1 needed regular verbal reminders to use their walker, staff did not return to R1’s room to assist R1 prior to breakfast time. Staff did realize around 06:30AM that R1’s roommate was present in the dining room and R1 wasn’t present as expected, so care staff went to R1’s room to check on them and found R1 in their room, face down on the floor with blood pooling by R1’s head. Med tech then assessed R1 and dialed 9-1-1 for further medical assistance.

Medical documentation for R1 revealed R1 was taken to Saint John’s Pleasant Valley Hospital Emergency Department (in Camarillo) via ambulance. R1 had a significant laceration and soft tissue swelling on the left side of their face in the periorbital area and R1 was transferred to the Saint John’s Regional Medical Center (in Oxnard) direct observation unit for further management. CT head scan showed left frontal subarachnoid hemorrhage (bleeding from a damaged blood vessel), 3mm small left subdural hematoma, left zygomatic arch fractures. CT maxillofacial showed nondisplaced fracture involving the lateral aspect of the left orbit posterior inferior left maxillary sinus mildly displaced fracture with soft tissue within the left maxillary sinus likely representing hemorrhage, buckling type fracture involving the left zygomatic Orange. The resident was admitted to the hospital. R1 was admitted to the Direct Observation Unit (DOU) and had neuro checks every 2 hours as per unit protocol. Prior to the fall, R1’s physician’s report indicated R1 had no concerns


Report Continued on LIC 9099-C (p.3)
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 8
Control Number 29-AS-20240102113855
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: 11/25/2024
NARRATIVE
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swallowing and R1 could self-feed. However, while in the hospital DOU, R1 experienced dysphagia on 12/29/2023 and failed swallow evaluations on 12/30/2023 and 12/31/2023. On 12/30/2023, a neurology consultation was conducted, and it was determined that R1 had a traumatic intracranial hemorrhage, facial fracture, status post-fall. On 01/01/2024, R1 experienced respiratory distress and with the development of tachycardia, the medical team discussed comfort care with R1’s responsible party. R1 was placed on palliative care and subsequently passed away in the hospital on 01/04/2024. Certificate of death listed sequelae of subdural and subarachnoid hemorrhage and blunt head trauma as the immediate cause of death. Coroner indicated the ground level fall took place on 12/28/2023 at approximately 06:15AM was the cause of the injury related to R1’s death. Based on interview and record review, the preponderance of evidence standard has been met, therefore the allegations “neglect/lack of supervision leading to questionable death” and “neglect/lack of supervision: facility employees failed to properly supervise resident resulting in an unwitnessed fall and multiple injuries to the resident” are deemed SUBSTANTIATED at this time.

Allegation: Licensee did not meet resident’s ADL needs:


All of R1’s annual physician’s reports dated 2021 – 2023 indicate R1 is unable to meet their own ADL needs and required assistance with the following: bathing, dressing/grooming, caring for toileting needs, and assistance with managing cash resources. R1’s care assessment dated 03/01/2023 also indicated R1 required “full assistance” with grooming and hygiene as well as dressing. This same care assessment indicated R1 used a walker for mobility and that R1 required transfer assistance “at times.” However, interview revealed that on the morning of 12/28/2023, staff went into R1’s room sometime between 05:30AM and 06:00AM and assisted R1 in getting dressed, but that staff had left R1 unsupervised in their room to comb their own hair and wash their own face. Staff stated they expected R1 to complete their own ADL care before walking themselves to the dining room. Both R1’s physician’s report dated 03/09/2023 as well as care assessment dated 03/01/2023 indicated R1 required full assistance with personal grooming and hygiene. Additionally, staff interviewed indicated that R1 used to be more independent but over time, has needed more assistance. Care staff admitted to not providing the ADL care outlined in R1’s care assessment, as they only provided assistance with dressing R1 and allowed R1 to complete additional ADL tasks without assistance or supervision, although R1 required full assistance with these activities. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the allegation “Licensee did not meet resident’s care needs” is deemed SUBSTANTIATED at this time.
Report Continued on LIC 9099-C (p.4)
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 29-AS-20240102113855
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: 11/25/2024
NARRATIVE
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Allegation: Licensee did not provide resident’s responsible party an updated care plan:
LPA reviewed care plans for R1, as well as conducted interviews with management and other facility staff. LPA also spoke with R1’s responsible party. R1’s responsible party stated they had not received a copy of R1’s care plan, nor had R1’s care plan been reviewed with R1’s responsible party. R1’s responsible party stated they “assumed that staff were assisting a 93 year old with dressing and personal care needs,” but stated they were never provided with a document specifying what ADL care was being provided to R1. Staff interviewed indicate they conduct care assessments every 6 (six) months on all residents, but that these are not reviewed with the residents nor their responsible parties. Care assessments reviewed for R1 did not contain a signature line to indicate the resident nor their responsible party had reviewed the document. The facility does not utilize the form Community Care Licensing Division (CCLD) provides on the Department website which does include a signature line, but instead the Licensee uses and in-house form. Facility Management was unable to provide written proof that a current care plan was provided to R1’s responsible party. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the allegation “Licensee did not provide resident’s responsible party an updated care plan” is deemed SUBSTANTIATED at this time.

Allegation: Licensee did not comply with reporting requirements:


The complaint alleges that R1’s responsible party was not informed either verbally nor in writing of the incident that occurred on 12/28/2023. Interview with R1’s responsible party revealed that they were out of town at the time of R1’s incident. R1’s responsible party indicated that they received a voicemail from the hospital on 12/29/2023, but that no voicemail nor missed call was received on their cell phone from the facility phone number or any other phone number possibly related to the facility. R1’s family member called the facility on 12/29/2023 to inquire about R1’s status, but the front desk staff could only confirm that R1 had been sent to the hospital but did not have any other details as to R1’s status and neither the med tech nor the Administrator were available at that time to speak with R1’s family member. The med tech did call R1’s responsible party back later that day. The med tech on duty at the time of the fall reported to CCL and to R1’s responsible party that they did not leave a message for R1’s responsible party. Med tech indicated they left a message for another one of R1’s family members, however, could not recall time the call was made nor whether the call was made using the facility telephone or the staff’s personal cell phone. Med tech did not allow LPA to review the call log on their personal cell phone, so LPA was unable to confirm whether either of the calls to R1’s family had been made. R1’s responsible party stated they spoke to the other family member Report Continued on LIC 9099-C (p.5)
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 29-AS-20240102113855
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: 11/25/2024
NARRATIVE
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and this person also had not received a missed call nor message from facility staff. Additionally, staff interviewed indicated although they did write an incident report related to R1’s fall and subsequent hospitalization, the written document was not provided to R1’s family member. Staff interviewed stated they do not provide a written report to any resident’s responsible party unless it is requested. Based on interview and record review, the preponderance of evidence standard has been, therefore the allegation “Licensee did not comply with reporting requirements” is deemed SUBSTANTIATED at this time.

A $1000 immediate civil penalty is assessed today. The administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f).

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies are cited (refer to LIC9099-D).

Exit interview conducted, appeal rights discussed, and a copy of this report issued.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 29-AS-20240102113855
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: 11/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/26/2024
Section Cited
CCR
87464(f)(4)
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87464 Basic Services (f) (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking...Postural Supports
This requirement is not met as evidenced by:
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Executive Director agreed to conduct an inservice training to all staff on this regulation section. Training will be scheduled and proof will be provided to CCL by POC due date.
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The licensee did not comply with the above cited section, as R1 was not provided full assist with ADL care as required in care assessment, which resulted in R1 falling and sustaining multiple fractures and R1 passing away as a result of injuries sustained, which posed an immediate health and safety risk.
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Type A
11/26/2024
Section Cited
CCR
87411(a)
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87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...adequate services.
This requirement is not met as evidenced by:
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Executive Director indicated there are additional staff scheduled on each shift to ensure adequate coverage. Training will be provided concurrent with the above basic services requirements and will provide proof of training to CCL by POC due date.
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The licensee did not comply with the above cited section, as staff were aware of R1's care needs and that R1 was a fall risk, however did not provide supervision as required, which posed an immediate health and safety risk 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: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 29-AS-20240102113855
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: 11/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/25/2024
Section Cited
CCR
87705(c)(6)
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87705 Care of Persons with Dementia
(c) (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals.
This requirement is not met as evidenced by:

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ED indicated the facility is now using the LIC 625 form for all reappraisals and have started reviewing the care plans with residents and responsible parties. POC cleared.
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The licensee did not comply with the above cited section, as R1 did not have a reappraisal reviewed with with R1 or their responsible party, which posed a potential health and personal rights risk to persons in care.
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Type B
11/25/2024
Section Cited
CCR
87211(a)(1)(B)
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87211 Reporting Requirements (a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days...(B) Any serious injury...under facility supervision.
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ED indicated that following this incident, the med room began utilizing a call log to document all telephone calls with resident families. ED will provide written reports by taking a photo and sending the report via text message to families. POC cleared.
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The facility did not comply with the above cited section, as no written report was provided to R1's responsible party, which posed a potential health, safety and personal rights risk 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: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 8