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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850158
Report Date: 09/07/2022
Date Signed: 09/07/2022 04:19:30 PM

Document Has Been Signed on 09/07/2022 04:19 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:GUTIERREZ, ROBERTFACILITY TYPE:
740
ADDRESS:903 CARMEN DRIVETELEPHONE:
(805) 586-4191
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 130CENSUS: 55DATE:
09/07/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:David AnguinigaTIME COMPLETED:
03:32 PM
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Licensing Program Analyst (LPA) Kelly Dulek conducted a case management visit today to address deficiencies observed during a facility tour. LPA met with Executive Director (ED) David Anguiniga and explained the reason for the visit. Entrance interview conducted.

During today's visit, LPA, along with ED toured the facility beginning at 10:17AM. During the facility tour, at 10:19AM, the door to the beauty salon, containing Barbicide liquid and scissors was observed unlocked and accessible to residents in care. At 10:22AM, crushed medications were observed on top of a medication cart, accessible to residents in care. At 10:34AM, in the memory care unit, a can of Febreze air freshener and several tubes of Calmoseptine cream were observed on a cart, accessible to residents in care. At 10:36AM, in the memory care unit, drawers containing scissors, nail clippers, hair detangling spray, incontinence wash, and Calmoseptine cream were observed to be unlocked,

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview was conducted with Executive Director David Anguiniga. Today’s reports and appeal rights were reviewed and provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2022
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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Document Has Been Signed on 09/07/2022 04:19 PM - It Cannot Be Edited


Created By: Kelly Dulek On 09/07/2022 at 02:39 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: 09/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/07/2022
Section Cited
CCR
87705(f)(1)

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87705 (f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
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Items were secured in a locked location during today's visit. Administrator agreed to provide training to all staff on section 87705(f) to all staff and provide proof to CCL to include name of trainer, date/time of training, topics covered, and a roster of attendees by 09/21/2022.
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Based on observation, during facility tour, scissors were observed in both the beauty salon at 10:19AM and in the memory care unit activity room at 10:36AM accessible to residents with dementia, which poses an immediate health and safety risk to residents in care.
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Type A
09/07/2022
Section Cited
CCR87705(f)(2)

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87705 (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication...and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
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Items were secured in a locked location during today's visit. Administrator agreed to provide training to all staff on section 87705(f) to all staff and provide proof to CCL to include name of trainer, date/time of training, topics covered, and a roster of attendees by 09/21/2022.
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Based on observation, during facility tour, Barbicide liquid was observed at10:19AM, crushed medications were observed at 10:22AM, Febreze was observed at 10:34AM and Calmoseptine cream was observed at 10:34AM and 10:36AM accessible to residents with dementia which poses an immediate health and 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.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Kelly Dulek
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2022


LIC809 (FAS) - (06/04)
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