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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850158
Report Date: 01/13/2025
Date Signed: 01/13/2025 11:07:18 AM

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
03/04/2024 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20240304113219
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: 82DATE:
01/13/2025
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Monica ReyesTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility staff is sleeping during NOC shift.
Facility staff do not treat residents with dignity and respect.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial complaint visit was conducted on 03/11/2024 by LPAs M. Arroyo and K. Dulek and a subsequent complaint visit was conducted on 01/02/2025 by LPA M. Arroyo. On today's visit, LPA Arroyo met with Executive Director (ED), Monica Reyes. Entrance interview.

During the initial visit on 03/11/2024, LPAs Arroyo and Dulek interviewed the Administrator at 09:07am, toured the facility at 09:32am, reviewed and obtained copies of documents pertinent to the investigation, interviewed staff at 10:45am, 10:48am and 1:24pm, residents at 10:42am and 10:53am, and reviewed medications beginning at 1:44pm. On 01/02/2025, LPA Arroyo conducted interviews with one staff and six residents between 12:55pm and 1:45pm and obtained copies of pertinent documents.

Report Continued on LIC 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025
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 6
Control Number 29-AS-20240304113219
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: 01/13/2025
NARRATIVE
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Report Continued from LIC 9099...

It was alleged that facility staff is sleeping during NOC shift. It was reported that staff will sleep 4 – 5 hours before getting up and assisting the residents in the morning. During the facility walkthrough, the LPAs observed that there was no camera in the 400’s hallway, and two rooms, 403 and 408, were both unlocked and vacant. However, the vacant rooms appeared clean during the walkthrough. Cameras were observed throughout the common areas and other hallways. During interviews with staff, they denied sleeping or observing other staff members sleeping during their shifts. Further interviews revealed that residents had not reported or made any complaints regarding a lack of assistance during the day or night. In interviews with residents, they denied observing or hearing about staff sleeping while working. Based on interviews conducted with staff and residents, the Department does not have sufficient evidence to support the allegation of “facility staff is sleeping during NOC shift”. Therefore, this allegation is deemed Unsubstantiated at this time.

It was also alleged that facility staff do not treat residents with dignity and respect. It was reported that residents have reported staff being rude, disrespectful, and handling rough when assisting. Interviews conducted with residents revealed that the staff are friendly and have not been treated differently from the other residents. Additionally, residents denied experiencing disrespect from facility staff or witnessing staff disrespecting other residents during assistance. Furthermore, six out of six residents interviewed expressed no concerns or complaints about how the staff treat them. Based on interviews conducted with residents, the Department has insufficient evidence to support the allegation of “facility staff do not treat residents with dignity and respect”. Therefore, this allegation is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
03/04/2024 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20240304113219

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: 82DATE:
01/13/2025
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Monica ReyesTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff did not assist residents with self-administration of medications as prescribed.
Facility staff is not sufficient in numbers and competent to provide adequate services to residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial complaint visit was conducted on 03/11/2024 by LPAs M. Arroyo and K. Dulek and a subsequent complaint visit was conducted on 01/02/2025 by LPA M. Arroyo. On today's visit, LPA Arroyo met with Executive Director (ED), Monica Reyes. Entrance interview.

During the initial visit on 03/11/2024, LPAs Arroyo and Dulek interviewed the Administrator at 09:07am, toured the facility at 09:32am, reviewed and obtained copies of documents pertinent to the investigation, interviewed staff at 10:45am, 10:48am and 1:24pm, residents at 10:42am and 10:53am, and reviewed medications beginning at 1:44pm. On 01/02/2025, LPA Arroyo conducted interviews with one staff and six residents between 12:55pm and 1:45pm and obtained copies of pertinent documents.

Report Continued on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20240304113219
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: 01/13/2025
NARRATIVE
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Report Continued from LIC 9099...

It was alleged that staff did not assist residents with self-administration of medication as prescribed. It was reported that medications are not being administered to residents at the appropriate times and other times medications are being left unattended causing residents to miss their dosage. On 03/11/2024, LPAs observed two random resident medications, the medication list, and the centrally stored medication and destruction records (CSMDR). According to Resident #1’s (R1’s) Medication List, dated 03/11/2024, it lists twenty (20) routine medications and eight (8) PRN medications for R1. Although R1’s Medication Administration Record (MAR) indicated that all prescribed medications were being administered, as the facility staff initials inidcated, certain medications such as Calcium Carbonate 1500mg, 600mg (1 tablet twice a day), Preservision AREDS Capsules (2 capsules daily), and Terbinafine HCL 250mg (1 tablet daily) were not observed or present with the other routine medications. Additionally, three (3) out of the eight (8) PRNs were found to be missing and not with R1’s medications. These missing PRNs included Albuterol Sulfate HFA 108, Mucus Relief 600mg, and Tizanidine HCL 4mg. Moreover, Resident #2 (R2) has a PRN medication, Albuterol Sulfate HFA 108 (inhale 2 puffs by mouth every 6 hours as needed for shortness of breath). However, during the medication review, it was revealed that R2’s PRN medication was empty and had not yet been refilled. Furthermore, residents’ medications were either missing or had not been refilled during medication review indicating residents are not taking their medications as prescribed. Based on medication review and LPAs observations, the Department has sufficient evidence to support the allegation of “staff did not assist residents with self-administration of medications as prescribed”. Therefore, this allegation is deemed Substantiated at this time.

It was also alleged that facility staff is not sufficient in numbers and competent to provide adequate services to residents in care. Record review and interviews conducted revealed that Staff #1 (S1) was hired by the facility on 02/05/2024 and began working on 02/15/2024. According to the staff schedule dated 02/18/2024 – 03/03/2024, S1 worked the NOC shift on 02/23/2024, 02/24/2024, 02/25/2024, 02/28/2024, 02/29/2024, 03/01/2024, and 03/02/2024. Interviews also revealed that S1 had been assisting residents with their activities of daily living (ADLs) prior to reaching the age of eighteen (18).

Report Continued on LIC 9099C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20240304113219
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: 01/13/2025
NARRATIVE
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Report Continued from LIC 9099C...

Furthermore, although two staff members were assisting residents, one of them did not meet the minimum qualifications required by state regulations. Based on the information obtained during the course of the investigation, the Department has sufficient evidence to support the allegation of “facility staff is not sufficient in numbers and competent to provide adequate services to residents in care”. Therefore, this allegation 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.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20240304113219
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: 01/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/17/2025
Section Cited
CCR
87465(a)(4)
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A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage... and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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Licensee will schedule medication training for all med-techs that includes documentation and medication distribution and submit proof to CCLD no later than POC due date.
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Based on record review, the Licensee did not comply with the section cited above as R1’s MAR indicates medication is being administered but medication was not found and R2 has missing PRN as staff has not reordered yet, which posed an immediate health and safety risk to residents in care.
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Type A
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Section Cited
CCR
87411(a)(b)
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Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… All persons who supervise employees or who supervise or care for residents shall be at least eighteen (18) years of age. This requirement was not met as evidenced by:
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Licensee will review Regulation 87411 and submit statement of understanding to CCLD no later than POC due date.
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Based on record review and interviews, the Licensee did not comply with the section cited above as S1 was assisting residents with ADLs but was not eighteen (18) years of age, 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: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6