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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850158
Report Date: 05/29/2024
Date Signed: 05/30/2024 08:22:20 AM

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
05/23/2024 and conducted by Evaluator Teresa Camara
COMPLAINT CONTROL NUMBER: 29-AS-20240523090009
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: 65DATE:
05/29/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Esmeralda Saucedo ElizarrarazTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff are making inappropriate comments towards residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Teresa Camara conducted an initial complaint investigation visit regarding the above noted allegation. LPA met with Resident Care Coordiantor (RCC) Esmeralda Saucedo Elizarraraz and explained the reason for the visit. The Administrator was out of the facility during LPA's visit.

At 2:33 p.m. LPA conducted an interview with RCC. At 2:50 p.m. LPA conducted a telephone interview with Administrator Monica Reyes. At 3:00 p.m. LPA reviewed pertinent records. At 3:15 p.m. LPA conducted an interview with Resident 1 (R1).


(continued on LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
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-20240523090009
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: 05/29/2024
NARRATIVE
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(continued from LIC9099)

During the interviews with LPA, the Administrator and RCC denied making any inappropriate comments toward R1. There have been discussions with R1 regarding incontinence care and R1's rights regarding such care.

R1 indicated they did not have any complaints. They denied being spoken to in a rude or inappropriate manner by staff. R1 stated "Everything's ok." They stated they get assistance with the care they require.

No deficiencies observed. Exit interview conducted and report issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2