565850158-5-30-2024-29-AS-DPEA-D5SRMS-20240531130913

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 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: 65	DATE:	05/29/2024
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Esmeralda Saucedo Elizarraraz		TIME 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 Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 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)

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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 Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 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)

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