565850158-1-25-2024-29-AS-KHEN-D2VVLS-20240228153224

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850158
Report Date: 01/25/2024
Date Signed: 01/25/2024 04:47:13 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
01/18/2024 and conducted by Evaluator Kelly Dulek

COMPLAINT CONTROL NUMBER: 29-AS-20240118113952

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:	10:08 AM
MET WITH:	Monica Reyes		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Staff neglect resulted in a resident leaving the facility unsupervised.

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 10:08AM and initially met with facility staff. LPA met with Executive Director (ED) Monica Reyes at 11:00AM. Entrance interview conducted.

During today's visit, 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 pertinent to the investigation. The following was then determined:

The complaint alleges that Resident #1 (R1) left the facility unassisted and was found in the community, was confused and had fallen. The Regional Office had also received an incident report on 01/16/2024 indicating that on 01/15/2024, R1 had left the facility and was found in the community. LPA sent an email to the ED requesting documents for R1, which were received on 01/18/2024. Record review indicated that R1 resides
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: 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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Control Number 29-AS-20240118113952

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: 01/25/2024

NARRATIVE

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in the facility's Assisted Living unit. Initial documents sent to LPA included a medical assessment dated 10/24/2022 and indicated R1 is able to leave the facility unassisted, although R1 was marked with a diagnosis of dementia and being non-ambulatory and unable to evacuate without assistance. LPA interviewed management staff, who indicated this is R1's most recent assessment and that faxes to R1's physician to request a new medical assessment went unanswered. However, during today's visit, LPA reviewed R1's medical assessment dated 10/24/2023 which indicates that R1 has a diagnosis of dementia and cannot leave the facility unassisted. Care assessment dated 10/21/2023 and filled out by Aasta facility staff indicates R1 requires "some supervision in the home and needs attendance when outside the home or tends to wander". Interviews revealed that staff were aware R1 tends to wander, had attempted to leave the facility previously, and due to these behaviors R1 was on status checks every 15 minutes throughout the day and night. On the day of the incident, staff had seen R1 around 04:30AM in the hallway. At approximately 05:30AM, the facility received a phone call from paramedics asking about R1, who had been found in the community. Management interviewed indicated that when the phone call was received the facility staff were unaware that R1 had left the facility. Additionally, interviews also revealed that on the day and time R1 left the facility, there was 1 (one) caregiving staff working in Memory Care, and one Med Tech/caregiver working in Assisted Living. An additional Memory Care caregiver arrived at the facility at 05:30AM, however, during the overnight shift there were only 2 (two) facility staff present for 55 residents residing in the facility. Interview revealed it is unclear how R1 exited the building, R1 was found approximately 1 mile from the facility and staff were unaware of R1's whereabouts at the time emergency responders inquired. Based on interview and record review, there is sufficient evidence to support the allegation, therefore, the allegation that "staff neglect resulted in a resident leaving the facility unassisted" 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. 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 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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20240118113952

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: 01/25/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/08/2024 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Executive Director agreed to provide additional vendorized training to staff on resident basic care and supervision and provide proof to CCL by POC due date.
	8 9 10 11 12 13 14	Based on interview and record review, the licensee did not comply with the above cited section, as R1 was on 15-minute status checks, yet on 01/15/2024, R1 left the facility unassisted and was found a mile away before staff were aware R1 left, which poses an immediate safety risk to residents 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: 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

LIC9099 (FAS) - (06/04)

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