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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850158
Report Date: 05/09/2024
Date Signed: 05/09/2024 03:46:37 PM


Document Has Been Signed on 05/09/2024 03:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
565850158
ADMINISTRATOR:REYES, MONICAFACILITY TYPE:
740
ADDRESS:903 CARMEN DRIVETELEPHONE:
(805) 586-4191
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:130CENSUS: 63DATE:
05/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:52 AM
MET WITH:Monica ReyesTIME COMPLETED:
04:00 PM
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Licensing Program Analysts (LPAs) Teresa Camara and Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 8:52 a.m. LPAs met with administrator Monica Reyes and explained the reason for the visit.

LPAs conducted a physical plant tour starting at 10:04 a.m. The tour was conducted with the Administrator. The physical plant areas were inspected inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The following was observed:

BEDROOMS: The facility consists of 106 total bedrooms, of which LPAs observed 11 resident bedrooms; 3 in the Meadows (Memory Care) and 8 in Assisted Living. All resident rooms observed were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Smoke detectors in rooms functioned properly, however two rooms that had been recently renovated lacked smoke detectors.

RESTROOMS: Each resident room contains its own private restroom. Resident restrooms observed contained sufficient grab bars and non-skid surfaces. Water temperatures ranged from 107.4*F to 120.7*F, however one room measured 122.1*F for which the administrator notified maintenance to adjust the water heater.

COMMON AREAS: Consisting of the lobby, library, activity room, dining room, bistro, and movie room in the Assisted Living side and activity room and dining room in the Meadows side. The LPAs observed common areas to be clean and properly furnished at the time of the visit. The LPAs observed the fire extinguishers to

(continued on LIC809-C)
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/09/2024 03:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in two out of ten rooms inspected they did not have smoke detectors, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2024
Plan of Correction
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Administrator had the facility maintenance person install new smoke detectors in these rooms during LPAs' visit. Administrator will ensure all rooms are inspected for smoke detectors after rooms are renovated.
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two out of five staff files. LPA reviewed Guardian roster and found two staff had fingerprint/background clearance but were not associated to this facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2024
Plan of Correction
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Administrator associated both staff to the facility during the LPAs' visit. Administrator will ensure the Guardian roster is reviewed on a regular basis to confirm all staff are cleared and associated to the facility.
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: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/09/2024
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(continued from LIC809)

be fully charged and last serviced on 02/08/2024. All hardwired smoke alarms as well as fire doors and sprinkler system were inspected during the five year fire inspection which took place on 05/18/2022 and were functional at that time. During today’s visit, LPAs checked the delayed egress doors in Meadows, which functioned properly. The combination smoke/carbon monoxide detectors in the hallways were tested and functioned properly. The temperature was maintained at a comfortable level throughout the building. Cleaning supplies and disinfectants are stored locked per regulation. The LPAs observed cameras in the common areas. LPAs observed the required postings in the common area.

OUTDOOR SPACE: LPAs observed the building and grounds in both Assisted Living and Memory Care. Multiple seating areas were observed with tables and chairs and shaded seating areas for resident use.

RECORD REVIEW: LPAs reviewed staff and resident records for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisals, and admission agreements. Five out of five staff files reviewed contained all documents, however two of the staff had fingerprint/background clearance but were not associated to this facility. Five out of five resident files reviewed contained all documents LPAs were reviewing.

MEDICATION REVIEW: LPAs conducted a medication review of four residents. All medications appeared to be given as prescribed. There were three residents with medications on a monthly cycle for which the Centrally Stored Medication and Destruction Record lacked a start date.

KITCHEN: LPAs observed the kitchen/dining area. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food, including emergency supply of food and water. LPAs inspected food for expiration dates; dates were clearly marked.

(continued on LIC809-C)

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/09/2024
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(continued from LIC809-C)


INFECTION CONTROL: During today’s visit, the LPAs spoke with the Administrator regarding the facility’s infection control practices. The facility’s policies and procedures as it pertains to infection control are adequate.

INTERVIEWS: Throughout today’s visit, LPAs interviewed 4 (four) staff and 4 (four) residents. No concerns noted.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC809 (FAS) - (06/04)
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