<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850158
Report Date: 05/05/2022
Date Signed: 05/06/2022 09:04:19 AM


Document Has Been Signed on 05/06/2022 09:04 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA



FACILITY NAME:AASTA ASSISTED LIVINGFACILITY NUMBER:
565850158
ADMINISTRATOR:GUTIERREZ, ROBERTFACILITY TYPE:
740
ADDRESS:903 CARMEN DRIVETELEPHONE:
(805) 586-4191
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:130CENSUS: 53DATE:
05/05/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:29 PM
MET WITH:Robert GutierrezTIME COMPLETED:
05:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management – Incident visit for the purpose of following up on a self-reported incident report received in the Woodland Hills Regional Office on 05/05/2022. LPA met with Administrator Robert Gutierrez and explained the reason for today's visit. Entrance interview conducted.

The written incident report contained information regarding an incident involving Resident #1 (R1) and Resident #2 (R2) that occurred in R2's room on 05/04/2022. During today's visit, LPA interviewed Wellness Director at 12:33 PM and Administrator at 12:38 PM regarding the incident. Additionally, LPA gathered documents pertinent to the investigation.

No immediate health and safety concerns were observed during today's visit.

LPA has determined further investigation is needed. The LPA will return at a later date to continue the investigation.

Exit interview conducted. A copy of the report was provided via email.

SUPERVISOR'S NAME: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022
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 1