565850158-5-6-2022-29-AS-KDUK-CE6LUZ-20220506090447

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850158
Report Date: 05/05/2022
Date Signed: 05/06/2022 09:05:12 AM

Document Has Been Signed on 05/06/2022 09:05 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 LIVING		FACILITY NUMBER:	565850158
ADMINISTRATOR:	GUTIERREZ, ROBERT		FACILITY TYPE:	740
ADDRESS:	903 CARMEN DRIVE		TELEPHONE:	(805) 586-4191
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	130	CENSUS: 53	DATE:	05/05/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:29 PM
MET WITH:	Robert Gutierrez		TIME 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 arrived at the facility unannounced to conduct a required annual visit at 12:29 PM. This annual had a specific emphasis on infection control practices and procedures. The LPA initially met with Wellness Director Elda Morales and discussed the reason for the visit. Administrator Robert Gutierrez arrived at the facility at 12:48 PM. Entrance interview conducted. At 1:33 PM, the 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. The following was observed: KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives were observed to be locked. COMMON SPACES: Indoor common areas consisting of the lobby, library, Garden Room, Activity Room, dining room, Bistro, and movie room in the Assisted Living side and Activity Room and dining room in Memory Care are clean and properly furnished. A working telephone is present. The LPA observed the required postings in the common area. Fire extinguishers throughout the building were observed to be fully charged and last serviced on 02/15/2022. All hard-wired smoke alarms and carbon monoxide detectors as well as fire doors were tested during the fire inspection on 4/2/2021. The locked medication room is located in the Assisted Living side of the facility. Facility laundry room is located next to the activity room. All supplies are locked in the laundry room. Report Continued on LIC 809-C

SUPERVISOR'S NAME:	TELEPHONE:
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE:
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)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: AASTA ASSISTED LIVING	FACILITY NUMBER: 565850158
	VISIT DATE: 05/05/2022

NARRATIVE

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Building and grounds were observed throughout today’s visit. Patio area observed with tables and chairs and shaded seating areas for resident use.

RESIDENT ROOMS/RESTROOMS: The facility has 107 bedrooms total – 24 in memory care and 83 in Assisted Living. Each resident room contains it's own restroom. Due to the situation surrounding Coronavirus 19 (COVID-19) and to implement mitigation measures, LPA did not observe occupied resident bedrooms/restrooms during today's visit. An empty recently remodeled resident room was observed to be clean and in good condition; the restroom contained sufficient grab bars and non-skid surfaces.

INFECTION CONTROL: During today’s visit, the LPA spoke with Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening and hand sanitization. LPA observed all staff to be wearing masks. The LPA observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies cited. Exit interview conducted. A copy of the report was provided via email.

SUPERVISOR'S NAME:	TELEPHONE:
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE:
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

LIC809 (FAS) - (06/04)

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