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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850158
Report Date: 08/12/2025
Date Signed: 08/12/2025 05:44:13 PM

Document Has Been Signed on 08/12/2025 05:44 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: 69DATE:
08/12/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:36 AM
MET WITH:Monica ReyesTIME VISIT/
INSPECTION COMPLETED:
05:55 PM
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Licensing Program Analysts (LPAs) Valeria Conway and Kelly Dulek conducted an unannounced case management – legal/non-compliance visit. The purpose of today’s visit is to ensure the facility is maintaining substantial compliance. Upon arrival, the LPAs met with Executive Director (ED), Monica Reyes and explained the reason for the visit. The LPAs focused today’s visit on physical plant, resident files and incident reporting in compliance with Title 22 Regulations.

During today's visit, the LPAs, along with ED, conducted a physical plant tour beginning at 11:23AM and LPA Dulek conducted file review at 01:26PM. The following was noted:

Upon arrival to the facility, LPAs observed the delayed egress gate on the north side of the memory care was observed to be tied shut with a plastic bag, preventing the gate from opening. During facility tour, at 11:50AM, the other delayed egress exit gate was observed to be locked with a key. Maintenance staff confirmed that the gate had been locked since Sunday 08/10/2025.

During file review, LPA Dulek reviewed files for 7 (seven) residents for documents including but not limited to: physician's reports, needs and service appraisals, and admission agreements. 2 (two) of 7 (seven) residents' files reviewed (Resident #1 - R1 and Resident #2 - R2) had needs and service appraisals that were more than 1 year old. Resident #3 (R3) has a needs and service appraisal dated 01/31/2025. However, based on review of incident reports and interview with staff, R3 has had a change in condition as evidenced by increased aggression and sexual behaviors, but staff did not complete a new needs and service appraisal for R3.


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: 08/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2025
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: 08/12/2025
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Additionally during today's visit, LPAs discussed with ED Reyes recent incident reports sent to Community Care Licensing. ED reported 3 (three) separate incidents involving R3, who resides in the facility's Memory Care unit. 2 (two) of these incidents occurred on 07/24/2025 and involved R3 showing aggressive behavior towards care staff and Resident #4 (R4). The third incident occurred on 08/03/2025 and involved R3 hitting R4, resulting in R4 requiring outside medical treatment. R3 was observed to be ambulatory and staff interview revealed that all resident doors are to remain locked to prevent R3 from unwanted/unsafe access to other resident rooms, as R3 had been involved in additional incidents previously. When touring the facility, ED stated that R4 had been moved to another room, so R3 and R4 no longer have a shared jack-and-jill style restroom.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Civil penalties issued in the amount of $1000, for a repeat violation. Executive Director was informed that failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted. A copy of today's report was provided via email.

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

DATE: 08/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/12/2025 05:44 PM - It Cannot Be Edited


Created By: Kelly Dulek On 08/12/2025 at 04:14 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: 08/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/13/2025
Section Cited
CCR
87202(a)

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87202(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal…district providing fire protection services, or the State Fire Marshal.
This requirement is not met as evidenced by:
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Executive Director ensured lock was unlocked, and plastic was removed during the visit. During today's visit, a door repair person visited the facility and identified a problem with the door latch. Repair person will complete repairs tomorrow and ED will provide proof to CCL by POC due date.
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Based on observation, the licensee did not comply with the above cited section, as both delayed egress exits from the memory care yard were observed to be locked and/or tied shut, which poses an immediate safety risk to residents in care.
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Additionally, the lock will be changed to limit access to and prevent staff from locking the back gate. Proof to be provided to CCL by POC due date.
Type A
08/13/2025
Section Cited
CCR87464(f)

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87464 (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
This requirement is not met as evidenced by:
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ED agreed to install a lock on the door from the shared restroom to the adjoining room. ED further agreed to assess potential residents R3 may have access to through the shared restroom for compatibility and safety prior to moving anyone into that room. ED will provide proof by POC due date.
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Based on interview and observation, the licensee did not comply with the above cited section, as R3 was allowed continued unsupervised access to R4, although R3 displayed aggressive behaviors towards others, resulting in R4 sustaining injury, which poses an immediate safety 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: 08/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/12/2025 05:44 PM - It Cannot Be Edited


Created By: Kelly Dulek On 08/12/2025 at 05:04 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: 08/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/26/2025
Section Cited
CCR
87463(a)

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87463 (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first...appraisal shall be referred to as the reappraisal.
This requirement is not met as evidenced by:
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ED agreed to complete reappraisals for the 3 residents identified and submit proof to CCL by POC due date.
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Based on record review and observation, the licensee did not comply with the above cited section, as 2 of 7 files reviewed did not have a reappraisal within a 12-month period and 1 of 7 had a change of condition with no reappraisal, which poses a potential health and safety 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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Kelly Dulek
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2025


LIC809 (FAS) - (06/04)
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