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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850158
Report Date: 03/21/2024
Date Signed: 03/21/2024 05:19:40 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
01/10/2023 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20230110153850
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: 58DATE:
03/21/2024
UNANNOUNCEDTIME BEGAN:
02:16 PM
MET WITH:Monica ReyesTIME COMPLETED:
05:25 PM
ALLEGATION(S):
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9
Facility did not assist resident with obtaining medical care
Facility staff did not assist resident with administering medications as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Kelly Dulek and Martha Arroyo conducted a subsequent complaint visit with the purpose of delivering findings for the allegations listed above. LPAs met with Monica Reyes at 02:16PM. Entrance interview conducted.

During the initial complaint visit conducted on 01/12/2023, LPA interviewed Administrator at 09:50AM and at various times throughout the visit, toured the facility with Administrator at 11:08AM, interviewed staff at 11:21AM, 12:42PM, and 01:04PM. LPA also gathered copies of pertinent documents. A referral was made to CCLD’s Investigations Branch (IB), was accepted for investigation, and assigned to IB investigator Douglas Real. Investigator Real received and reviewed a copy of Resident #1 (R1)’s hospital records and conducted either telephonic or in-person interviews with facility staff, residents and other pertinent parties on the following dates: 02/09/2023, 02/13/2023, 04/10/2023, and 04/11/2023. The following was then determined:

Report Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
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 6
Control Number 29-AS-20230110153850
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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The complaint alleges that the facility staff did not assist Resident #1 (R1) in obtaining medical care nor did the facility assist the resident with self-administration of prescribed medications, both of which led to R1’s worsening medical conditions and subsequent hospitalization. Record review revealed that R1 had an extensive medical history, however R1’s medical conditions were managed through use of prescribed medications. Interviews revealed that R1, among many other residents, use the facility-contracted pharmacy provider. Around October 2022, the facility began to change contracted pharmacy providers to Concierge RX Pharmacy. The new pharmacy had a policy requiring residents to keep a card on file for all potential payments. R1 was one of approximately 8 (eight) residents who did not have a card on file. Interviews revealed that the pharmacy contacted these residents and/or their responsible parties to rectify the payment situation, and all residents’ payments except for R1’s were resolved. Interviews also revealed that the pharmacy attempted to contact R1’s brother, however, it was confirmed R1 was their own responsible party. It is unclear why R1’s brother was contacted, but interviews revealed facility staff did not directly assist the resident in rectifying the payment method. Beginning in November 2022, Concierge RX Pharmacy filled medication orders for residents residing at Aasta Assisted Living, including R1. However, R1 still did not have a credit card to keep on file, so the pharmacy did not deliver R1’s medications for December 2022. Facility staff indicated they sent faxes to R1’s primary care physician to inform the medical provider that R1 had not received their medications, however the facility’s fax machine did not provide confirmation the faxes were sent nor received. Interview with R1’s primary medical care provider revealed the facility staff never contacted the physician via telephone and no faxes were received at the medical office. R1’s physician was unaware R1 had not received medication in December 2022. Review of R1’s Medication Administration Record (MAR) revealed that R1’s MAR was marked as “med not available” on 12/01/2022, but was initialed as administered on 12/02/2022 and the entry for 12/03/2022 was empty. Interview revealed that R1’s MAR was incorrectly marked and R1 did not have any medications on any date in December 2022.

By 12/22/2022, it was observed that R1 wasn’t feeling well and was experiencing shortness of breath. On this date, facility staff offered to take R1 to the bank to request a debit card, however R1 wasn’t feeling well and declined an outing to the bank. Although R1 was experiencing shortness of breath and difficulty breathing, facility staff did not call 9-1-1 nor was additional medical care requested for R1. On 12/23/2022, facility staff did take R1 to the bank to order a debit card, however, at this point R1 had already been without medication for 23 days since 12/01/2022. Over the next week, R1’s difficulty breathing worsened and on 12/31/2022,
Report Continued on LIC-9099-C
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
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)
Page: 2 of 6
Control Number 29-AS-20230110153850
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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9-1-1 was called. R1 was admitted to the hospital on the same day and noted to be severely hypoxic – with fluid in their lungs. Medical professionals indicated that R1’s shortness of breath and difficulty breathing were likely caused by a buildup of fluid in R1’s lungs. R1 was previously prescribed medications to prevent buildup of fluid in their lungs, but this medication was not provided to R1 from 12/01/2022 to the date of R1’s hospitalization on 12/31/2022. R1, who used the facility-contracted pharmacy, relied on the facility to obtain and provide medications and the facility staff failed to do either. None of the staff attempted to notify R1’s physician by telephone nor did any staff attempt to get the resident’s prescription medications at a different pharmacy. Although the Admission Agreement, signed by R1 on 07/18/2021, indicates that “I authorize the Community to place an emergency order for medication(s) that has not been timely provided by me or my pharmacy,” at no time in December did the facility staff place an emergency order for R1’s medications. Interviews with facility staff confirmed their efforts to assist R1 in obtaining their medications were insufficient. Based on interview and record review, there is sufficient evidence to support the allegations, therefore, the allegations “facility staff did not assist resident in obtaining medical care” and “facility staff did not assist resident with administering medications as prescribed” are deemed SUBSTANTIATED at this time.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 9099-D).

A $1000 immediate repeat civil penalty for the citation related to CCR 87464(f)(1) is assessed today. Another $250 civil penalty is assessed for the citation related to CCR 87465(a)(4) for a repeat violation. The Administrator Monica Reyes was informed that additional civil penalties might be assessed based on health and safety code 1569.49(f).

Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
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)
Page: 3 of 6
Control Number 29-AS-20230110153850
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: 03/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/25/2024
Section Cited
CCR
87464(f)(1)
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87464(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:
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Administrator agreed to submit a plan on how the facility will ensure residents' basic services will be met and provide proof to CCL by POC due date.
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Based on interview and record review, the licensee did not comply with the above cited section, as facility staff did not assist R1 in rectifying the payment issue with the facility-contracted pharmacy nor assist R1 in obtaining medical care which poses an immediate health risk to residents in care.
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Type A
03/25/2024
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility....4) The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced by:
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Administrator agreed to provide an inservice with an alternate outside vendor. The training will be scheduled and Administrator will provide proof of the scheduled training by POC due date. Following the training, Administrator will send proof of completion to CCL.
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Based on interview and record review, the licensee did not comply with the above cited section, as facility staff did not assist R1 in obtaining their medications, so no prescribed medications were available to administer for the month of December 2022, which posed an immediate health risk to residents 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.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC9099 (FAS) - (06/04)
Page: 4 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
01/10/2023 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20230110153850

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: 58DATE:
03/21/2024
UNANNOUNCEDTIME BEGAN:
02:16 PM
MET WITH:Monica ReyesTIME COMPLETED:
05:25 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Neglect/Lack of Care & Supervision – questionable death
INVESTIGATION FINDINGS:
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3
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5
6
7
8
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10
11
12
13
Licensing Program Analysts (LPAs) Kelly Dulek and Martha Arroyo conducted a subsequent complaint visit with the purpose of delivering findings for the allegations listed above. LPAs met with Monica Reyes at 02:16PM. Entrance interview conducted.

During the initial complaint visit conducted on 01/12/2023, LPA interviewed Administrator at 09:50AM and at various times throughout the visit, toured the facility with Administrator at 11:08AM, interviewed staff at 11:21AM, 12:42PM, and 01:04PM. LPA also gathered copies of pertinent documents. A referral was made to CCLD’s Investigations Branch (IB), was accepted for investigation, and assigned to IB investigator Douglas Real. Investigator Real received and reviewed a copy of Resident #1 (R1)’s hospital records and conducted either telephonic or in-person interviews with facility staff, residents and other pertinent parties on the following dates: 02/09/2023, 02/13/2023, 04/10/2023, and 04/11/2023. The following was then determined:

Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
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: 5 of 6
Control Number 29-AS-20230110153850
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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The complaint alleges that R1 died as a result of neglect and/or lack of care and supervision, as R1 did not receive their medications, nor did the facility staff assist R1 in obtaining medical care. Record review revealed that R1 had an extensive medical history, however R1’s medical conditions were managed through use of prescribed medications. Record review and interview revealed that R1 did not receive their medications in the month of December 2022 due to the facility’s contracted pharmacy requiring a specific payment method, which R1 did not have access to. R1 was observed on 12/22/2022 to be experiencing shortness of breath and trouble breathing. Over the next 9 days, R1’s condition worsened, resulting in facility staff calling 9-1-1 on 12/31/2022 due to R1’s trouble breathing. R1 was admitted to the hospital the same day due to progressively worsening shortness of breath. R1 was severely hypoxic on transfer to the hospital. A chest x-ray was done and the findings indicated bilateral lung infiltrates (right greater than left) and moderate right pleural effusion. Upon admit to the hospital, R1 was treated with aggressive diuresis, but did not respond well and had worsening azotemia (according to WebMD, azotemia is a buildup of blood urea nitrogen and creatine in the blood.) R1 had consultations with cardiology and pulmonary and initially agreed to undergo further cardiac work-up but changed their mind and decided to be on palliative care. R1 began palliative care on 01/04/2023. R1 passed away at the hospital on 01/07/2023. R1’s cause of death was listed as acute diastolic congestive heart failure secondary to critical aortic stenosis. Other causes were listed as urinary tract infection, hypertension and coronary artery disease. Although R1 was prescribed medication to prevent buildup of fluid in R1’s lungs which is caused by R1’s chronic heart failure, R1’s physician, when interviewed, would not speculate if R1’s death was caused by not getting their medication in December. Based on interview and record review, although the allegation may be valid, but at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation “Neglect/Lack of Care & Supervision – questionable death” is deemed UNSUBSTANTIATED at this time.

No citations issued related to this allegation. Exit interview conducted. A copy of the report was provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
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)
Page: 6 of 6