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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850158
Report Date: 07/11/2025
Date Signed: 07/11/2025 05:41:08 PM

Document Has Been Signed on 07/11/2025 05:41 PM - 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:AASTA ASSISTED LIVINGFACILITY NUMBER:
565850158
ADMINISTRATOR/
DIRECTOR:		REYES, MONICAFACILITY TYPE:
740
ADDRESS:903 CARMEN DRIVETELEPHONE:
(805) 586-4191
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 130CENSUS: 72DATE:
07/11/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Monica ReyesTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Kelly Dulek and Valeria Conway conducted an unannounced visit at the facility in conjunction with a complaint investigation that occurred today.Executive Director and LPA attempted to call Licensee to review the report via telephone, however, Licensee did not answer the calls.

During the investigation, LPAs observed deficiencies unrelated to the complaint allegations, which will be addressed in this report. An Interim Management Service Agreement was sent by email to the LPAs on 07/07/2025, which indicates "new operator is taking over as of today under management agreement." The management agreement was signed by authorized representative of Affinity Garden Manor, LLC Pogos Tofalyan on 07/07/2025. Both Administrator and representative of Affinity Garden Manor LLC also indicated that Affinity Garden Manor is acting as a management company for the current Licensee, as described in the terms of the Interim Management Service Agreement. Residents interviewed during today’s visit stated that they were given new Admission Agreements for the change of ownership and residents reported the new owners have taken over operations of the facility this week. Aasta Assisted Living issued payroll checks labeled "final check" to employees on 07/07/2025, but were unsure which entity will be issuing ongoing payroll checks. Review of Interim Management Service Agreement indicates "IMC shall be responsible for the supervision, staffing and employment of employees...all employees of the facility shall be employees of the IMC." LPAs observed that all of the licensee's belongings have been removed from the facility. LPA contacted CCLD's Centralized Applications Bureau (CAB) to inquire whether an application had been submitted for the management company, per regulation. CAB indicated that there had not been an application to include a Management Company under the current license, nor had a change of ownership

Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Kelly Dulek
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2025
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 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: AASTA ASSISTED LIVING
FACILITY NUMBER: 565850158
VISIT DATE: 07/11/2025
NARRATIVE
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application been received for the property at the time of the LPA's inquiry. LPA reviewed an online webpage for Affinity Garden Manor located at this address although the application has not yet been received nor approved, but is being advertised as in operation.

Additionally, interviews revealed that an excluded individual, Anna Hakobyan, was present at the facility on Monday 07/07/2025. Record review revealed that representative Agnes Gazaryan Lazar has been present at the facility every day since 07/07/2025 and does have a criminal background clearance, however was not associated to the facility until 07/10/2025.

Pursuant to Title 22 of the CA Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D). Civil penalties issued in the amount of $900. Executive Director was informed that failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted, today's reports, civil penalties and appeal rights were reviewed and issued.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Kelly Dulek
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/11/2025 05:41 PM - It Cannot Be Edited


Created By: Kelly Dulek On 07/11/2025 at 04:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AASTA ASSISTED LIVING
FACILITY NUMBER: 565850158

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/11/2025
Section Cited
HSC
1569.58(a)(2)

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1569.58 (a) (2) Engaged in conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility, or the people of the State of California.

This requirement is not met as evidenced by:
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Executive Director understand and will ensure going forward excluded individuals will not be present at the facility. POC cleared
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Based on interview, the licensee did not comply with the above cited section, as on 07/07/2025, an excluded individual was present at the facility, which posed an immediate health and safety risk to persons in care.
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Type B
07/11/2025
Section Cited
CCR87355(e)(3)

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87355 (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c)
This requirement is not met as evidenced by:
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Executive Director associated the staff on 07/10/2025. POC cleared.
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Based on interview and record review, the licensee did not comply with the above cited section, as an individual began working at the facility on 07/07/25 and background clearance was not transferred until 07/10/25, which posed a potential 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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Kelly Dulek
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 07/11/2025 05:41 PM - It Cannot Be Edited


Created By: Kelly Dulek On 07/11/2025 at 05:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AASTA ASSISTED LIVING
FACILITY NUMBER: 565850158

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/18/2025
Section Cited
HSC
1569.191(b)

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§1569.191 Sale of licensed facility; resulting issuance of new license; procedure (b) Except as...the property and business shall not be transferred until the buyer qualifies for a license or provisional license within the appropriate provisions of this chapter.
This requirement is not met as evidenced by:
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Executive Director agreed to discuss with Licensee and Licensee will communicate with CCLD related to the change of ownership by POC due date.
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Based on record review and interview, the licensee did not comply with the above cited section, as interim management service agreement is in effect 07/07/25 and no application was submitted to CCLD to reflect the addition of a management company, which poses a potential risk to residents.
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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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Kelly Dulek
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2025


LIC809 (FAS) - (06/04)
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