565850158-5-14-2024-29-AS-DPEA-D5RPJB-20240530112116

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850158
Report Date: 05/14/2024
Date Signed: 05/14/2024 04:48:27 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
05/09/2024 and conducted by Evaluator Teresa Camara

COMPLAINT CONTROL NUMBER: 29-AS-20240509154156

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: 63	DATE:	05/14/2024
		UNANNOUNCED	TIME BEGAN:	12:32 PM
MET WITH:	Monica Reyes		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Staff did not treat resident with dignity or respect.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Teresa Camara conducted an initial complaint investigation visit. LPA was greeted by the administrator Monica Reyes and LPA explained the reason for the visit.

At 12:33 LPA interviewed the administrator. At 12:51 LPA reviewed records for resident 1 (R1). At 1:28 p.m. LPA interviewed R1. At 1:47 p.m. LPA interviewed staff 1 (S1).

The complaint indicated R1 had gone to the front desk to have documents faxed but the staff treated R1 disrespecfully when the resident requested a fax confirmation sheet. However, R1 is not physically capable of going to the front dest on their own and chooses to stay in their room unless they must leave for an appointment. R1 takes all their meals in their room. R1 communicated to LPA that was not what happened. R1 stated it was "not a major issue" and did not wish to pursue this complaint.

(continued on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20240509154156

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: 05/14/2024

NARRATIVE

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(continued from LIC9099)

During the interview with S1, they were not aware of R1 needing to fax any documents recently but recalled approximately one month ago R1 needed to fax documents but did not have the fax number. S1 stated they never laughed at R1 or made fun of them. S1 told R1 they would hold the documents and give them to their conservator when the conservator visited.

Neither the administrator or S1 witnessed any staff treat R1 with disrespect. The administrator stated approximately three weeks ago they had a meeting with R1, staff and R1's conservator to ensure that R1's concerns about certain staff were addressed. The administrator stated they have gone out of their accommodate R1's needs and wishes.

Based on the interview with R1, this complaint was not correct and R1 did not wish to pursue the complaint. Therefore, the allegation staff did not treat resident with dignity and respect is deemed unsubstantiated at this time.

No deficiencies observed. Exit interview conducted and report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024

LIC9099 (FAS) - (06/04)

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