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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850158
Report Date: 05/29/2025
Date Signed: 05/29/2025 08:25:40 PM

Substantiated


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
02/25/2025 and conducted by Evaluator Valeria Conway
COMPLAINT CONTROL NUMBER: 29-AS-20250225161613
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: 76DATE:
05/29/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Monica ReyesTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Due to lack of supervision, resident hit another resident causing injury
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Valeria Conway, Kelly Dulek, Martha Arroyo and Licensing Program Manager (LPM) Kristin Heffernan, conducted a subsequent unannounced complaint visit to
the facility above to deliver final findings of the complaint allegations. At 10:30 A.M., LPA Conway met with Executive. Director (ED), Monica Reyes, and explained the purpose of the visit.

On 02/26/2025, LPA Conway interviewed Wellness Director at 8:55 AM, ED at 9:30 A.M., toured Memory Care (MC) with ED at 10:30 A.M., reviewed residents’ files for Resident #1 (R1) and Resident #2 (R2) at 9:45 A.M., and requested time cards and department schedule for staff working at the time of the incident. LPA also reviewed and obtained copies of documents pertinent to the investigation. The following was determined.

Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025
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 3
Control Number 29-AS-20250225161613
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: 05/29/2025
NARRATIVE
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Continued from LIC9099

On the allegation: “Due to lack of supervision, resident hit another resident causing injury" The Responsible Party (RP) expressed concern that they believes the staff to resident ration is poor or inadequate. During the initial visit, LPA Conway conducted interviews with the two (2) residents involved in the reported incident. However, due to both individuals having a diagnosis of dementia, neither resident was able to clearly recall or articulate the events that took place on that day.

LPA interviewed facility ED stating that she was not present at the facility when the incident occurred but reported that staff responded to the residents promptly.

During staff interviews, it was consistently reported that the facility is experiencing ongoing staffing shortages, which has made it increasingly difficult for caregivers to adequately attend to all residents' needs. Staffs acknowledged that facility policy mandates 15 minute safety checks, however, these are not being properly conducted due to insufficient personnel, stating that it is not possible to conduct these checks as require and as a result, residents are at risk of injury. In fact, due to the current staffing situation, there have been multiple incidents involving resident hitting other residents and falls that required hospitalization. Additionally, staff reported that certain caregivers are frequently observed using their personal phones during work hours, resulting in inadequate supervision and reduced attention to residents' needs and safety.

Based on information and the evidence gathered during the course of the investigation, there is sufficient evidence to determine that due to lack of supervision a resident hit another resident causing an injury. Therefore, the above allegation “Due to lack of supervision, resident hit another resident causing injury” is deemed SUBSTANTIATED at this time.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties.

An immediate civil penalty of $1,000 repeat violation is assessed today due to being cited for the same violation within 12 months. Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f).

Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20250225161613
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/30/2025
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements General (a) Facility personnel shall at all times be sufficient in numbers... In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure...This requirement is not met as evidenced by…
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ED stated that four new indiviuals are in the process of being hired by AASTA and agrees to write a statement of understanding reg 87411 (a), submit a plan of action to prevent these events before POC due date.
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Based on interviews and record review the Executive Director did not comply with the regulation above by not having sufficient support staff and supervision to perform essential duties for residents in care which poses a potential health, safety and personal rights 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.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025
LIC9099 (FAS) - (06/04)
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