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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850158
Report Date: 10/14/2024
Date Signed: 10/15/2024 08:13:34 AM

Document Has Been Signed on 10/15/2024 08:13 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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: 80DATE:
10/14/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Monica ReyesTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Valeria Conway and Kelly Dulek, conducted an unannounced Case Management – Incident visit. The purpose of the visit is to investigate self-reported incident report submitted to the Department on 10/07/2024. Upon arrival, LPAs met with front desk staff. Administrator, Monica Reyes, was called via phone. At 11:35 a.m., Administrator arrived at the facility. Reason for the visit was explained. Entrance interview.

The Incident report submitted noted that on 10/06/2024 at 1:30 p.m., a staff member noticed Resident #1 (R1) walking in the Memory Care (MC) garden area. Per incident report, “R1 was doing activities and they had just seen him walk in, and then after five (5) minutes they (staff members) looked again and R1 was no longer there”. Staff members then called the Administrator and the Sheriff Department. At 1:45 p.m., R1 was found across the street walking around the park. On 10/10/2024, LPA Conway, conducted a phone interview with facility Administrator Monica Reyes between 10:35 a.m. and 10:47 a.m. During the interview Administrator stated that Resident 1 (R1) have been triggering the emergency alarms frequently since R1 was admitted on 10/04/2024. Administrator confirmed that R1 eloped from the facility by jumping a fence surrounding the Memory Care (MC) garden. No injuries were reported, and family members were informed.

Continued on LIC 809-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: AASTA ASSISTED LIVING
FACILITY NUMBER: 565850158
VISIT DATE: 10/14/2024
NARRATIVE
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Continued from LIC 809-C

During today's visit the LPAs conducted a tour of the Memory Care unit at 12:30 p.m. LPAs interviewed Administrator and random staff members between 10:30 a.m. and 2:30 p.m. LPAs also reviewed facility records and obtained pertinent copies. During the record review, LPA Conway reviewed the pre-admission appraisal for R1, physician’s report, dated on 09/24/2024, and the Care Assessment and Service Plan. Documentation indicates that R1 is confused/disoriented and has wandering behavior confirming the resident’s tendency to wander. According to the Administrator, following R1’s elopement, staff are providing close supervision while the resident is in the garden. Furthermore, administrator’s recommendation to R1’s responsible party is to hire a private caregiver to help prevent R1 from leaving the facility. LPA’s attempted to interview R1, however R1 was unable to communicate in English. LPA’s asked Administrator to demonstrate that the delay egress side gates were functioning properly during the visit. Between 1:10 p.m. - 1:15 p.m. both gates were tested, and the alarm was triggered when the bars were pushed.

Pursuant to Title 22 of the CA Code of Regulations and Health and Safety Code, the following deficiencies were cited (refer to LIC 809-Ds): Exit interview conducted and copy of the report was issued and appeal rights provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024
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Document Has Been Signed on 10/15/2024 08:13 AM - It Cannot Be Edited


Created By: Valeria Conway On 10/14/2024 at 02:53 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: 10/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/15/2024
Section Cited
CCR
1569.312(a)

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1569.312 Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services:(a) Care and supervision as defined in Section 1569.2.
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The licensee will submit a written plan describing how staff will ensure protocols for residents who require additional supervision while in care. Additionally, in-service training in the memory care unit about how to prevent an elopment of a resident. Submit proof to CCL by POC due date. Training by 10/28/24
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Based on record review and interview Facility staff did not ensure to provide the necessary care and supervision to Resident #1 which allowed Resident #1 to elope from the facility unassisted, 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:Desaree Perera
LICENSING EVALUATOR NAME:Valeria Conway
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2024


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