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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850158
Report Date: 04/29/2025
Date Signed: 04/30/2025 08:45:44 AM

Document Has Been Signed on 04/30/2025 08:45 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: 81DATE:
04/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Esmeralda ElizarrarazTIME VISIT/
INSPECTION COMPLETED:
07:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Valeria Conway and Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 9:40 A.M. Upon arrival, the LPAs met with the receptionist, who advised administrator, Monica Reyes of the LPAs presence. Administrator was unavailable during today's visit. Nandita Ashley Kumar, Marketing Director, arrived at 10:10 A.M. and explained that Resident Care Coordinator (RCC), Esmeralda Elizarraraz will be authorized to sign today's reports. At this time, the reason for the visit was explained. Entrance interview conducted.

The LPAs conducted a physical plant tour starting at 10:31 A.M along with the RCC and the Marketing Director. The physical plant areas were inspected inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. This facility doesn’t have a staff room, facility will provide 24/7 care. The following was observed:



BEDROOMS: The facility consists of 106 total bedrooms, of which LPAs observed 15 random resident bedrooms; five (5) in the Meadows (Memory Care) and ten (10) in Assisted Living. All resident rooms observed were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The LPAs checked smoke detectors in the 15-bedroom observed and they were functional at the time of the visit.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 10
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 04/30/2025 08:45 AM - It Cannot Be Edited


Created By: Valeria Conway On 04/29/2025 at 05:28 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: 04/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
87705(d)
(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observations, the licensee did not comply with the section cited above as 3 out of 5 emergency exit door were not functioning properly when tested at the time of the visit, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2025
Plan of Correction
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The Licensee will have emergency exit doors fixed and send viedo as proof to CCL no later than POC due date.
Type A
Section Cited
CCR
87303(a)
(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:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above as feces was observed in the courtyard of the Meadows accessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2025
Plan of Correction
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The Licensee will have area cleaned up and send pictures to CCL no later than POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2025


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 04/30/2025 08:45 AM - It Cannot Be Edited


Created By: Valeria Conway On 04/29/2025 at 05:28 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: 04/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
87303(e)(3)
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation, the licensee did not comply with the section cited above as six out of 15 bathrooms checked measured above 120 degrees Fahrenheit, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2025
Plan of Correction
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The Licensee adjusted the water temperature during the inspection.

POC has been met.
Type A
Section Cited
CCR
87465(a)(4)
(a)A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on medication review, the licensee did not comply with the section cited above as medication quantity did not match that of the CSMDR and no refusals were noted, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2025
Plan of Correction
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The Licensee will schedule a third party vendor to conduct medication training and submit proof to CCL no later than POC due date.

After training completetion, the Licensee will submit training records to CCL.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2025


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 04/30/2025 08:45 AM - It Cannot Be Edited


Created By: Valeria Conway On 04/29/2025 at 05:28 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: 04/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87470(4)(c)
(4) All facility staff and volunteers shall use gloves as a protective barrier to prevent the spread of potential infection as specified below. (C)Gloves shall be removed and discarded in the nearest appropriate waste receptacle with a tight-fitting cover immediately following the glove use as required by subsection (a)(4)(A) with one resident and prior to an interaction with another resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation, the licensee did not comply with the section cited above as gloves and incontinence bed pads were observed disposed of in a regular trash can without a tight-fitting lid, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2025
Plan of Correction
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The Licensee will replace necessary trash cans and send proof to CCL no later than POC due date.
Request Denied
Type A
Section Cited
CCR
87615(a)(5)
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (5) Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as 1 out of 8 files reviewed indicate resident has no capacity for self-care and is not on hospice, or have approved exception on file with the department, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2025
Plan of Correction
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The Licensee will submit updated physician's report or exception request to CCL no later than POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2025


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 04/30/2025 08:45 AM - It Cannot Be Edited


Created By: Valeria Conway On 04/29/2025 at 05:28 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: 04/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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4
Deficiency Dismissed
Type B
Section Cited
CCR
87307(a)(3)(D)
(D) Hygiene items of general use such as soap and toilet paper.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above as 1 out of 5 bathrooms did not have toilet paper and 5 out of 5 bathrooms did not have paper towels accesible to residents and visitors, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2025
Plan of Correction
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The Licensee will place paper towels and toilet paper in all bathrooms and submit proof to CCL no later than POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2025


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 04/30/2025 08:45 AM - It Cannot Be Edited


Created By: Valeria Conway On 04/29/2025 at 05:28 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: 04/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(6)
Personnel Requirements - General
(6) The licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2). For on-the-job training, documentation shall consist of a statement or notation, made by the trainer, of the content covered in the training. Each item of documentation shall include a notation that indicates which of the criteria of Section 87411(c)(3) is met by the trainer.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as 4 out of 8 staff files reviewed did not have required training filed and were not accesible during the inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2025
Plan of Correction
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The Licensee will send missing training documents or complete necessary training and send to CCL no later than POC due date.
Type B
Section Cited
CCR
87457(c)(1)(A)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall document, at a minimum: (A) An evaluation of the prospective resident's functional capabilities, mental condition, and social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as 8 out od 8 appraisals were incomplete and not filled out properly, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2025
Plan of Correction
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The Licensee will complete appraisals for the 8 residents and send proof to CCL no later than POC due date.

The Licensee will review all apprisals and complete if necessary.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2025


LIC809 (FAS) - (06/04)
Page: 7 of 10
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: 04/29/2025
NARRATIVE
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Contined from LIC 809

RESTROOMS: Each resident room contains its own private restroom. Resident restrooms observed contained sufficient grab bars and slip-resistant surfaces. The LPAs conducted an inspection of 5 restrooms in the Meadows and 10 restrooms in the Assisted Living Unit. The LPAs observed that one (1) out of five (5) restrooms did not have toilet paper available. Additionally, 5 out of the 5 restrooms in the Meadows were observed to have paper towel dispensers empty and regular trash cans. LPAs observed used gloves and used incontinence bed pads inside trash cans at the time of the visit. Between 10:44 A.M. and 12:21 P.M. the LPAs measured hot water temperatures in all fifteen (15) restrooms, six (6) out of fifteen (15) restrooms measured above the regulation range of 120 degrees Fahrenheit.

COMMON AREAS: Consisting of the lobby, library, activity room, dining room, bistro, and theater room in the Assisted Living side and activity room and dining room in the Meadows side. The LPAs observed common areas to be clean and properly furnished at the time of the visit. The LPAs observed two (2) unlocked drawers in the Meadows common areas with a heavy-duty metal 3-hole puncher, a tape dispenser and two (2) metal staplers accessible to residents in care. Fire extinguishers were observed throughout the facility and were fully charged and last serviced on 02/20/2025. All smoke alarms as well as fire doors and sprinkler system were inspected during the five-year fire inspection which took place on 05/18/2022 and were functional at that time. The combination smoke/carbon monoxide detectors in the hallways were tested and functioned properly. During today’s visit, 5 emergency exits were tested and two (2) out of five (5) required new batteries and the emergency exit leading to staff parking lot was deactivated when tested. RCC activated door immediately and maintenance personnel replaced batteries for the emergency exit for the other two (2) doors. However, the emergency exit on the theater room must be replaced. The temperature was maintained at a comfortable level throughout the building. Cleaning supplies and disinfectants are stored locked per regulation. The LPAs observed cameras in the common areas. The LPAs observed the required postings in the common area.



Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
LIC809 (FAS) - (06/04)
Page: 8 of 10
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: 04/29/2025
NARRATIVE
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Continued from LIC 809-C

OUTDOOR SPACE: The LPAs observed the building and grounds in both Assisted Living and Memory Care. Multiple seating areas were observed with tables and chairs and shaded seating areas for resident use. During today’s visit, the LPAs inspected the two (2) side delayed egress doors located in the Meadows. At 11:11 A.M. LPA Conway applied pressure to the egress door from the metal frame and observed the egress door connecting the Meadows to the Assisted Living unit did not secure properly. Additionally, the door failed to trigger the required alarm when opened. RCC called maintenance personnel to check on the door. Maintenance staff stated that the magnet keeping the door shut was out of place and need it to be adjusted. Furthermore, LPAs observed fecal matter through the perimeter of the Meadows’s courtyard, accessible to residents in care.

RECORD REVIEW: Between 1:03 P.M. and 3:20 P.M. LPA Arroyo reviewed 8 staff and 8 resident records for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisals, and admission agreements. During record review, the LPAs were unable to determine the number of training hours completed per regulation for the past twelve (12) months as training records were unavailable during the inspection for four (4) out of eight (8) staff files. All other staff records reviewed contained all required documentation. Eight (8) out of eight (8) resident files reviewed contained all documents, however, on the appraisal/needs and services plan pages two (2) to five (5) did not contain required information to identify individual needs or to develop a service plan for meeting resident needs. Also, two (2) out of eight (8) forms did not have required signatures from the facility’s representative and resident or resident’s responsible party.

Additionally, one (1) out of eight (8) resident files reviewed indicated that resident has no capability for self-care, is not on hospice, and there were no records indicating that an exception request was submitted to the department.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
LIC809 (FAS) - (06/04)
Page: 9 of 10
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: 04/29/2025
NARRATIVE
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Continued from LIC 809-C

MEDICATION REVIEW: At 2:25 P.M. LPA Conway and RCC conducted a medication review of five (5) residents. Facility documents prescribed medications in the Centrally Stored Medication and Destruction Record (CSMDR). CSMDR lacked a start date. The LPA observed start dates written on the cap of each bottled medication, however, one medication observed did not have a start date and neither Med-Techs present during the inspection or the RCC were aware of medication’s start date on the medication bottle. Additionally, the LPA found discrepancies in five (5) out of five (5) resident’s medication, where the pill counts within bubble packs and the medication bottles did not match the records documented on the CSMDR. Med-Techs on duty were unaware of these discrepancies or how these errors occurred.

KITCHEN: The LPAs observed the kitchen/dining area. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food, including emergency supply of food and water. The LPAs inspected food for expiration dates; dates were clearly marked.

INFECTION CONTROL: During today’s visit, the LPAs spoke with staff regarding the facility’s infection control practices. The facility’s policies and procedures as it pertains to infection control are adequate. Last emergency drill was documented on 03/21/2025.


INTERVIEWS: Throughout today’s visit, LPAs interviewed 4 (four) staff and 4 (four) residents. No concerns noted.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided. A repeat violation civil penalty was issued for $1000.00

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
LIC809 (FAS) - (06/04)
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