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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850158
Report Date: 07/22/2021
Date Signed: 09/01/2021 03:02:37 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:AASTA ASSISTED LIVINGFACILITY NUMBER:
565850158
ADMINISTRATOR:HULL, DYLANFACILITY TYPE:
740
ADDRESS:903 CARMEN DRIVETELEPHONE:
(818) 317-9565
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:130CENSUS: 77DATE:
07/22/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Robert GutierrezTIME COMPLETED:
05:24 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility to conduct a Post Licensing visit. LPA observed construction in the front lobby, so there is an alternate entrance and front desk set up nearby. Upon arrival, front desk staff conducted a COVID-19 screening and contacted the Administrator Robert Gutierrez. Entrance interview conducted.

LPA, along with Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Today's evaluation included, but was not limited to, building and grounds, resident rooms, bathrooms, common areas, personal accommodations, hot water temperature in resident bathrooms, kitchen and food supplies. Currently the facility is undergoing renovations; LPA and Administrator conversed extensively about the plans to minimize resident impact during construction. There is an adequate amount of perishable and nonperishable foods. LPA observed fire extinguishers recently serviced and fully charged. Centrally stored medicines are kept in a locked medication room. First Aid kit is complete. Grab bars were present in the bathrooms. LPA observed appropriate and sufficient furnishings and lighting in each room. Hygiene items are being provided. Administrator provided documentation of fire alarm system testing, which took place on 7/15/2021, with no functional defects found. LPA observed disaster plan posted hallway. LPA observed COVID-19 postings throughout the facility. LPA observed a 30-day supply of PPE. LPA reviewed a sampling of resident medications and records. LPA reviewed a sampling of staff records.



During facility tour, in the Memory Care unit, at 12:17PM, LPA observed a can of Febreze air freshener in Resident #1 (R1)’s room. At 12:20PM, LPA observed Neutrogena face wash and 2 (two) tubes of toothpaste in Resident #2 (R2)’s room. Both rooms were observed unlocked and located in the Memory Care unit.

During a review of resident records starting at 1:17PM, LPA observed that some resident Admissions
Report Continued on LIC 809-C
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/22/2021
NARRATIVE
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Agreements have not been updated since the Change of Ownership took place on 5/1/2021.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted. Today's reports and appeal rights were reviewed and emailed to the Administrator.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/23/2021
Section Cited

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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:(2) Over-the-counter medication...and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
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During facility tour, LPA observed Febreze Air Freshener spray and Snuggle air freshener in a resident room in the Memory Care unit, which poses an immediate safety 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: 09/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2021
LIC809 (FAS) - (06/04)
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