565850158-9-15-2023-29-AS-KHEN-DACLL8-20241024085039

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850158
Report Date: 09/15/2023
Date Signed: 09/15/2023 03:11:45 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/08/2023 and conducted by Evaluator Kelly Dulek

COMPLAINT CONTROL NUMBER: 29-AS-20230908154939

FACILITY NAME:	AASTA ASSISTED LIVING		FACILITY NUMBER:	565850158
ADMINISTRATOR:	REYES, MONICA		FACILITY TYPE:	740
ADDRESS:	903 CARMEN DRIVE		TELEPHONE:	(805) 586-4191
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	130	CENSUS: 61	DATE:	09/15/2023
		UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Monica Reyes		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Licensee did not assist resident with self-administration of medications as prescribed

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint investigation for the allegations listed above. LPA arrived at the facility at 11:25AM and met with Wellness Director Esmeralda Elizarraraz. Executive Director (ED) Monica Reyes arrived at 12:20PM. Entrance interview conducted.

During today's visit, LPA interviewed Wellness Director at 11:30AM, ED at 12:20PM, toured Memory Care with ED at 12:40PM, reviewed medications for Resident #1 (R1) at 12:47PM, and staff between 01:32PM and 2:20PM. LPA also reviewed and obtained copies of documents pertinent to the investigation. The following was then determined:

During the medication review, R1's medication Mirtazipine 15mg bottle indicated there were 30 count and the medication was started on 08/03/2023. Mirtazipine is ordered once daily and administered in the morning. 36 days elapsed from the date the bottle was opened to the date R1 was hospitalized on 09/07/2023, however
REPORT CONTINUED ON LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 29-AS-20230908154939

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AASTA ASSISTED LIVING	FACILITY NUMBER: 565850158
	VISIT DATE: 09/15/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

12 pills remain in the bottle, indicating only 18 doses were administered over the 36 day period. Medication Administration Record (MAR) reviewed did not indicate any medications were refused and contained blank spaces or x marked on different dates, instead of initials indicating the staff administered the medication. R1's medication ripseriDONE 2mg tablet originally contained 60 pills and 38 remain in the bottle during today's count. The MAR indicates the bottle was opened on 08/19/2023 and 20 days elapsed from that date to R1's hospitalization. RisperiDONE is ordered twice a day, therefore 39 doses should have been administered from the start date, but only 22 doses were utilized. Again, MAR was missing staff initials and had x marked on various dates, but no doses marked as refused. R1's Divalproex Sodium 125mg TBEC originally contained 240 capsules and during today's count 176 capsules remain. This medication is ordered 4 capsules to be administered twice a day. Start date is marked on the MAR as 08/18/2023 and on the bottle as 08/19/2023, so either 20 or 21 days have elapsed since the start date to the time of R1's hospitalization, so if the medication was administered as ordered, either 160 or 168 capsules should have been used. However, only 64 capsules were used. Again, R1's MAR has blank spaces or x marked on various dates but no refusals indicated. Based on interview and medication review, there is sufficient evidence to support the allegation, therefore, the allegation that "Licensee did not assist resident with self-administration of medications as prescribed" is deemed SUBSTANTIATED at this time.

The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. As this is a repeat violation, civil penalty issued in the amount of $250. Failure to correct the deficiency may result in additional civil penalties.

Exit interview conducted. A copy of the report, civil penalty and appeal rights were provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20230908154939

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AASTA ASSISTED LIVING	FACILITY NUMBER: 565850158
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/15/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/29/2023 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care Services (a) (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to conduct a medication audit for all residents and a training for all medication technicians on proper medication administration and documentation and provide proof of training and medication audit to CCL by POC due date.
	8 9 10 11 12 13 14	Based on medication review, the licensee did not comply with the above cited section, as 3 medications for R1, based on start date and assumed daily administration did not contain the appropriate amount of doses and MAR was inaccurate, which poses an immediate health risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4