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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850158
Report Date: 01/26/2026
Date Signed: 01/26/2026 02:48:26 PM

Document Has Been Signed on 01/26/2026 02:48 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:		DENISE GILROYFACILITY TYPE:
740
ADDRESS:903 CARMEN DRIVETELEPHONE:
(805) 586-4191
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 130CENSUS: 71DATE:
01/26/2026
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:17 AM
MET WITH:Agnes Gazaryan, Facility DesigneeTIME VISIT/
INSPECTION COMPLETED:
02:55 PM
NARRATIVE
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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 Facility Designee Agnes Gazaryan and explained the reason for the visit. LPAs were informed Administrator was not available during today's visit. The LPAs focused today’s visit on physical plant and medication administration in compliance with Title 22 Regulations.

During today's visit, the LPAs, along with Facility Designee, conducted a physical plant tour beginning at 12:37PM and LPA Dulek conducted a medication review at 01:47PM. The following was noted:

During the physical plant tour, LPAs observed feces in a planter in the outdoor area of the memory care unit. An unidentified brown substance was observed on the wall above the planter area where the feces was observed. Additionally, a hose was observed running down the outer wall of the memory care unit. Maintenance Director stated the gutter was damaged and fell off the wall during a recent storm. LPA Dulek reviewed medications for four (4) residents. Resident #1 (R1)'s medication trazodone 100mg was signed as administered, however was not popped from the bubble pack for one (1) day. For Resident #2 (R2), Rosuvastatin Calcium 20mg is initialed as administered, but was not found. All four (4) residents reviewed appeared to have medications administered for the 22nd during the day and the night shift on the 24th and 25th, however, they were not initialed as administered on the Medication Administration Record.

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 $500, for repeat violations. Facility Designee 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: 01/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2026
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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Document Has Been Signed on 01/26/2026 02:48 PM - It Cannot Be Edited


Created By: Kelly Dulek On 01/26/2026 at 01:24 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: 01/26/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/02/2026
Section Cited
CCR
87303(a)

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(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
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Facility Designee called Maintenance Director and ensured the feces and outer wall were cleaned during today's visit. Gutter will be replaced within a week; proof of completion will be sent to CCL by POC due date.
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Based on observation, the licensee did not comply with the above cited section, as feces was observed in the courtyard of the Meadows accessible to residents in care, additionally gutter was broken which poses an immediate health and personal rights risk to persons in care.
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Type A
02/09/2026
Section Cited
CCR87465(a)(4)

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87465(a)(4) (a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced by:
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Facility Designee plans to audit the medications for all residents and re-educate all medication technicians. Proof of re-education will be provided to CCL by POC due date.
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Based on observation and record review, the licensee did not comply with the above cited section, as R1's medication was marked administered but was still in the bubble pack, R2's medication could not be located, and MAR did not reflect medications administered, which poses an immediate 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: 01/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2026


LIC809 (FAS) - (06/04)
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