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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850158
Report Date: 07/22/2025
Date Signed: 07/22/2025 05:08:28 PM

Document Has Been Signed on 07/22/2025 05:08 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:
07/22/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:41 AM
MET WITH:Monica ReyesTIME VISIT/
INSPECTION COMPLETED:
05:15 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. LPAs met with Executive Director (ED) Monica Reyes and explained the reason for today’s visit. Entrance interview conducted.

During today’s facility tour, conducted with the ED and began at 11:19AM, LPAs observed the exhaust fan in the facility’s commercial kitchen to be non-operational. Staff interviewed stated that the exhaust fan has been broken for 2 (two) weeks. Kitchen staff have continued to use the burners and ovens located underneath the exhaust fan/hood, even though the hood is clearly labeled “CAUTION Exhaust fan must be turned on before lighting cooking appliances.” While in the kitchen, LPAs observed a kitchen staff with a burner lit and pot on the stovetop cooking. LPA Dulek spoke with Fire Inspector over the phone, who indicated the exhaust fan is an integral part of the facility’s fire safety system and must be functional at all times. Additional concerns in the kitchen related to maintenance are as follows: walk in freezer is broken and is being utilized as a refrigerator, kitchen vent is very dirty and does not allow air to flow into the kitchen area, and dishwasher is broken.

During medication review, which began at 12:53PM, LPAs observed Resident #1 (R1) was recently hospitalized twice related to their diabetes diagnosis. Prior to R1’s hospitalization, R1 was prescribed oral medication for diabetes control and had an order to check blood sugar twice daily before meals. Following the first hospitalization, R1’s medications were changed and R1 required regular daily insulin injections as well as blood sugar checks twice daily. After R1’s second hospitalization, R1’s medications were changed again, and as of 07/19/2025, R1 was prescribed insulin on a sliding scale. R1 has a diagnosis of dementia

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: 07/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2025
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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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: 07/22/2025
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and is residing in the facility’s memory care unit. R1 is unable to determine the amount of insulin to be injected per the sliding scale. Staff interviewed stated residents requiring injectable insulin are assisted by medication technicians using hand-over-hand; the medications are not administered by skilled professionals.

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 $1000, as this is a repeat citation. 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: 07/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/22/2025 05:08 PM - It Cannot Be Edited


Created By: Kelly Dulek On 07/22/2025 at 03:30 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: 07/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/23/2025
Section Cited
CCR
87203

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87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This requirement is not met as evidenced by:
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During today's visit, ED called the company that conducted the recent inspection and is now scheduled at the facility tomorrow morning. ED understands the cooktop and ovens beneath the exhaust hood are not permitted to be used until the fan has been
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Based on observation and interview, the licensee did not comply with the above cited section, as the exhaust fan has been broken for 2 weeks, is not repaired and staff have continued to cook with an inoperable fan, which poses an immediate health and safety risk to persons in care.
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repaired. Proof of completed repairs will be sent to CCLDprior to using the commercial kitchen equipment again.
Type A
07/23/2025
Section Cited
CCR87628(a)

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87628 Diabetes (a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to... medication administered orally or through injection, or has it administered by an appropriately skilled professional.
This requirement is not met as evidenced by:
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ED agreed to contact R1's physician and obtain medically appropriate orders for R1 to self-administer. ED will provide a written statement of understanding related to diabetic care and residents' ability to self-administer medications.
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Based on interview and record review, the licensee did not comply with the above cited section, as R1 has injectable medication prescribed on a sliding scale and a diagnosis of dementia and unable to check their own blood sugar and determine the amount, which poses an immediate health risk.
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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: 07/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2025


LIC809 (FAS) - (06/04)
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