565850158-3-21-2024-29-AS-DPEA-D3TQQJ-20240329122224

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850158
Report Date: 03/21/2024
Date Signed: 03/21/2024 05:16:01 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
01/25/2023 and conducted by Evaluator Martha Arroyo

COMPLAINT CONTROL NUMBER: 29-AS-20230125131322

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: 58	DATE:	03/21/2024
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Monica Reyes		TIME COMPLETED:	05:20 PM

ALLEGATION(S):

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Neglect/Lack of Care and Supervision - the facility staff did not ensure Resident #1 (R1) had oxygen resulting in brain injury.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Martha Arroyo and Kelly Dulek conducted a subsequent complaint visit to deliver findings for the above allegation. LPAs met with Administrator, Monica Reyes and explained the reason for the visit.

On 01/25/2023, the Department received a complaint regarding an allegation of Neglect/Lack of Supervision. It was alleged that the facility staff did not ensure Resident #1 (R1) had oxygen resulting in brain injury. The complaint was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Douglas Real.

On 01/26/2023, from 1:30 p.m. to 3:45 p.m., Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced initial complaint inspection for the allegation listed above.

Continued on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

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 3

Control Number 29-AS-20230125131322

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: 03/21/2024

NARRATIVE

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Continued from LIC 9099...

LPA Dulek met with the Administrator Monica Reyes and explained the reason for the visit. The LPA interviewed the Administrator at 1:30 p.m., and at various times throughout the visit. The LPA toured the facility with the Administrator at 1:50 p.m. and gathered copies of pertinent documents. No immediate health and safety concerns were identified during the facility tour.

On 01/28/2023, Investigator Real conducted interviews with R1’s resident representative; on 02/13/2023, from around 1:00 p.m. to 4:00 p.m., with a hospice employee and facility employees; on 02/14/2023, at around 11:00 a.m., with Witness #1 (W1); on 03/14/2023, from around 10:00 a.m. to 11:00 a.m., with facility employees; on 04/10/2023 and 04/11/2023, from around 2:25 p.m. to 2:30 p.m., with facility residents; and on 04/23/2023, at around 2:42 p.m., with a hospice nurse. In addition, Investigator Real reviewed Physicians Preferred Hospice records, 01/24/2023 video camera footage of R1’s bedroom at the facility, R1’s Physician Report, and other case-related documents. The case was also referred to the Departments Program Clinical Consultant (PCC) for review.

A review of R1’s Physician Report, dated 08/22/2022, indicated the primary diagnosis was metastatic breast cancer and secondary diagnosis was listed as back pain. R1’s health status was listed as poor and R1 was identified as confused and disoriented. On 08/25/2022, R1 was placed on hospice care with Physicians Preferred Hospice and had an order for oxygen as needed (PRN). On 10/01/2022, R1 was admitted to the facility.

The video camera footage reviewed of R1’s room on 01/24/2023 revealed a med tech placed an oxygen tank next to R1’s bed and attached R1 to the tank via nose tube at around 9:16 a.m. The med tech checked on R1 later, around 10:40 a.m. and again at 11:35 a.m. No further checks by the med tech were done. Throughout the day various caregivers checked on R1. However, none of the caregivers nor the PM med tech checked on R1’s oxygen tank level until around 6:56 p.m.

Continued on LIC 9099C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230125131322

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: 03/21/2024

NARRATIVE

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Continued from LIC 9099C...

The video footage further revealed a med tech checked on R1 at 6:00 p.m. at which point it appeared the tank was discovered to be empty. At around 6:45 p.m., the video shows R1’s resident representative checked the oxygen tank and replaced the tank with another machine around 7:00 p.m.

According to information obtained from Investigator Real’s interviews, R1’s resident representative felt R1 suffered brain damage because the oxygen had run out in the oxygen tank. However, records reviewed did not reflect a medical diagnosis of R1 suffering brain damage. The hospice employees reported R1 was on hospice and R1’s health had declined to the point they began using supplemental oxygen as a comfort care measure. The hospice staff had no abuse or neglect concerns regarding the facility employees. W1 regularly visited R1 in the facility and had no abuse or neglect concerns and did not believe R1 suffered any brain damage due to the oxygen tank running out. PCC review reflected that per facility staff and hospice nurses, the resident was not observed to be deprived of oxygen beyond slight shortness of breath as her baseline, there was no evidence that indicated the resident lost consciousness during that period, the lack of oxygen did not result in serious injury that meets the definition of Serious Bodily Injury as defined in Section 15610.67 of the Welfare and Institutions Code.

The information and evidence obtained during the Department’s investigation did not sufficiently support the allegation, therefore the allegation “Neglect/Lack of Care and Supervision - the facility staff did not ensure Resident #1 (R1) had oxygen resulting in brain injury” is deemed Unsubstantiated at this time.

Citations for violations unrelated to the complaint allegation will be cited on a separate report.

Exit interview. A copy of the report was provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

LIC9099 (FAS) - (06/04)

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