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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850158
Report Date: 05/10/2022
Date Signed: 05/10/2022 01:08:21 PM


Document Has Been Signed on 05/10/2022 01:08 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,
, 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:
05/10/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:09 PM
MET WITH:Robert GutierrezTIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management – Incident visit for the purpose of a subsequent visit following up on a self-reported incident report received in the Woodland Hills Regional Office on 05/04/2022. 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 at 12:25PM, LPA, along with Administrator, reviewed the camera footage for the date of the incident. LPA interviewed Administrator throughout the visit, and LPA and Administrator toured the Memory Care at 12:58PM.

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: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
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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