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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850158
Report Date: 03/21/2024
Date Signed: 03/21/2024 05:13:41 PM

Document Has Been Signed on 03/21/2024 05:13 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:REYES, MONICAFACILITY TYPE:
740
ADDRESS:903 CARMEN DRIVETELEPHONE:
(805) 586-4191
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 130CENSUS: 58DATE:
03/21/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Monica ReyesTIME COMPLETED:
05:20 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Martha Arroyo and Kelly Dulek conducted an unannounced Case Management Deficiency visit in conjunction with complaint visit (CC#29-AS-20230125131322). Upon arrival, LPAs met with Administrator, Monica Reyes. The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint.

Based on the review of the medical records, DSS investigative findings, and other miscellaneous documents, the facility AM med tech placed R1 on supplemental oxygen via a portable oxygen tank (PRN) on 01/24/2023 around 9:15 a.m. The facility employee last checked on R1 around 11:30 a.m. and no one checked on R1’s oxygen tank level or oxygen saturation level until around 6:50 p.m. In addition, it appears a lack of communication between facility employees resulted in the AM and PM caregivers not knowing who placed R1 on oxygen. The PM med tech failed to regularly monitor R1’s oxygen and oxygen tank level. Numerous facility employees checked on R1 throughout the day and attended to R1’s other needs but failed to address R1’s oxygen needs or change out the empty oxygen tank.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 809-D). Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. Citations issued. A Copy of report and appeal rights provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2024
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 03/21/2024 05:13 PM - It Cannot Be Edited


Created By: Martha Arroyo On 03/21/2024 at 03:19 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: 03/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
03/25/2024
Section Cited
CCR
87468.2(a)(4)

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Additional Personal Rights of Residents in Privately Operated Facilities. To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
This requirement is not met as evidence by:
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The Administrator will review Regulation 87468.2 and submit a plan on how the facility will ensure residents basic services/needs will be met. Submit to CCL no later than 03/25/2024.
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Based on interview, and record review, the licensee did not comply with the section above, as facility staff failed to regularly monitor R1’s oxygen and oxygen tank level, which posed an immediate health and safety risk to resident 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:Desaree Perera
LICENSING EVALUATOR NAME:Martha Arroyo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024


LIC809 (FAS) - (06/04)
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