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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850158
Report Date: 07/02/2025
Date Signed: 07/03/2025 07:29:18 AM

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
06/24/2025 and conducted by Evaluator Valeria Conway
COMPLAINT CONTROL NUMBER: 29-AS-20250624085732
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: 72DATE:
07/02/2025
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Monica ReyesTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff do not ensure residents are provided a mattress in good condition.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Valeria Conway and Kelly Dulek and Investigator from the Community Care Licensing Division (CCLD) Investigations Branch (IB) Rocio Flores conducted an unannounced initial complaint visit to investigate the allegation listed above. Upon arrival LPAs and Investigator met with Executive Director/Administrator, Monica Reyes, and explained the reason for the visit.

During today’s visit from 9:50 A.M.– 2:30 P.M. LPAs, investigator, and administrator toured the physical plant to ensure there are no health and safety concerns, and the facility is in compliance with Title 22 regulation. A case management report will be issued to address deficiencies observed during the physical plant tour. Additionally, LPAs and investigator interviewed staff, residents, and reviewed and obtained pertinent documents relevant to the investigation.

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

DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
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-20250624085732
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: 07/02/2025
NARRATIVE
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Continued from LIC 9099-C

Regarding the allegation: “Staff do not ensure residents are provided a mattress in good condition” as it was alleged that resident’s bed at the facility has a hole in the middle and the facility refuses to replace it.

During today’s visit, LPAs and investigator conducted a physical plant tour and inspected multiple resident rooms. In two (2) of the rooms visited, the mattresses were observed to be worn down and had a visible dip in the middle. Resident interviews revealed concerns regarding the quality of the mattresses. Residents reported that the mattresses are hard, uncomfortable, and due to their deteriorated condition, they are unable to turn, reposition themselves, or sleep comfortably. LPAs and investigator observed that mattresses in question were not in good condition and presented with noticeable dents and signs of wear. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that some beds had visible dents and signs of wear. Therefore, the above allegation “Staff do not ensure residents are provided a mattress in good condition” is deemed SUBSTANTIATED at this time.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 9099-D). Failure to correct the deficiencies may result in additional civil penalties.



Exit interview conducted, appeal rights discussed, and a copy of report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20250624085732
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: 07/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/16/2025
Section Cited
CCR
87307(a)(3)(A)
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87307(a)(3)(A) Personal Accommodations and Services.(a) Living accommodations...The facility shall...provide comfortable living accommodations...The following provisions shall apply:(3) ...the licensee shall assure provision of:(A)A bed for each resident...Each bed shall...good springs, a clean and comfortable mattress...This requirement is not met as evidenced by…
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Administrator will assess all resident rooms create list identifying any worn-out matressess and replace all mattresses to be in poor condition. A copy of the completed list, including room numbers and confirmation of replacements, will be submitted to LPA before POC due date.
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Based on observation, the licensee did not comply with the section cited above by not providing a comfortable mattress to residents in care, which poses a potential health, safety or personal rights risk to persons 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: 07/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
LIC9099 (FAS) - (06/04)
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