565850158-3-1-2024-29-AS-KLOZ-D4PMA4-20240426092544

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850158
Report Date: 03/01/2024
Date Signed: 03/01/2024 03:53:19 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
02/23/2024 and conducted by Evaluator Esther Cortez

COMPLAINT CONTROL NUMBER: 29-AS-20240223083928

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: 56	DATE:	03/01/2024
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Monica Reyes		TIME COMPLETED:	04:05 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not ensuring that resident is provided with a comfortable mattress.
Staff are not addressing resident's burn injury

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced initial 10-day complaint visit for the above allegations. Upon arrival, the LPA met with the Executive Director (ED), Monica Reyes, and was explained the reason for the visit. Entrance interview conducted.

During today's inspection, between 09:35 a.m. and 4:00 p.m., the LPA interviewed the Administrator, two (2) staff, resident #1, R1's hospice nurse, and R1's case manager, conducted a file review, and obtained copies of resident records and other pertinent documents relevant to the investigation.

Report will continue on LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024

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 2

Control Number 29-AS-20240223083928

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AASTA ASSISTED LIVING	FACILITY NUMBER: 565850158
	VISIT DATE: 03/01/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Regarding the allegations: Staff are not ensuring that resident is provided with a comfortable mattress and
Staff are not addressing resident's burn injury it is the reporting party’s concern that Resident #1 (R1) had sustained level one degree burns on their elbow and their left side of their body from their mattress. To investigate the complaint the LPA conducted a tour, conducted a file review of R1’s records, and conducted interviews. At 10:30 a.m. the LPA conducted a brief tour of R1’s bedroom and observed R1’s bed. The LPA observed a thin air mattress on top of a foam mattress. The LPA touched the air mattress, and the foam mattress and both mattresses did not feel hot. The LPA did not observe or felt any heat coming from the mattresses and did not feel any metals inside the air mattress. File review of R1’s records revealed that R1 is on hospice and has a doctor’s order for a hospital bed with half rails and an alternating pressure (APP) mattress from their hospice agency. Staff interviews revealed that they have not seen any burn injuries on R1 or any other resident. In addition, the administrator stated that residents on hospice are provided with beds from their hospice agencies. Interview with R1’s hospice nurse, revealed that R1 is seen once a week or as needed, a full body assessment is done at every visit, and R1 has not been observed with burn injuries. R1’s hospice nurse also revealed that R1 has a callus on their left elbow from always having their elbow on the same place and lack of circulation. Furthermore, the hospice nurse revealed that R1’s skin is looking better, and that even though R1 is a high risk for skin problems and that the bed is helping they can replace the bed at any time if there’s any concerns. Lastly, R1’s case manager from R1’s conservator’s office revealed that they do not have any concerns regarding R1’s bed causing the resident burns. Based on the information gathered, although the allegations may be valid, at this time there is insufficient evidence to support the allegations or that a violation occurred; therefore, the allegations that " Staff are not ensuring that resident is provided with a comfortable mattress” and " Staff are not addressing resident's burn injury,” are deemed UNSUBSTANTIATED at this time.

No citations issued. Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2