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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850158
Report Date: 04/22/2026
Date Signed: 04/22/2026 07:05:07 PM

Document Has Been Signed on 04/22/2026 07:05 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: 62DATE:
04/22/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Denise Gilroy, Agnes Gazaryan, & Gloria MoralesTIME VISIT/
INSPECTION COMPLETED:
07:10 PM
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Licensing Program Analysts (LPAs) Kelly Dulek and Angela Barutyan conducted a pre-licensing change of ownership visit to this property at 09:45AM. During the course of the visit, deficiencies were observed and addressed with the current Administrator Denise Gilroy, and designees Agnes Gazaryan and Gloria Morales.

Facility tour began at 10:45AM. Hot water was measured in a sample of six (6) resident rooms. Temperature readings were inconsistent throughout the facility, measuring between 83.4 degrees Fahrenheit and 131.0 degrees Fahrenheit. Designee informed maintenance staff and called a plumber, who visited the facility during the visit. Water temperatures were adjusted during the visit.

At 10:47AM, LPAs facility designee observed an unlocked drawer in the memory care common area, which contained wound cleanser, lotions, shaving cream, and other various personal care and grooming items. Staff holding the key was called to the area to secure the items during the visit. One (1) resident's room in Assisted Living was observed dirty, with feces on the toilet. Designee called housekeeping and requested additional cleaning in this resident's room. A light in a common bathroom, as well as one in the 200's hallway were observed flickering and/or too dim for sufficient visibility. Maintenance replaced the light bulbs during the visit.

LPAs observed the two (2) delayed egress points at the end of the Memory Care hallways leading to the outside patio were not turned on during the visit. There are two (2) additional delayed egress points upon exiting the Memory Care patio, which were tested and functional at the time of the visit. LPA Dulek called and spoke with Fire Inspector Richard Martinez at 02:38PM, who indicated he will review facility layout, fire codes and contact LPA with an update on permissible use of the delayed egress.

Report continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Kelly Dulek
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2026
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/22/2026
NARRATIVE
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During resident file review, LPAs reviewed five (5) resident files. Of the five (5) residents (Resident #1 - R1, Resident #2 - R2, Resident #3 - R3, Resident #4 - R4, and Resident #5 - R5), LPAs observed two (2) resident files (R1 and R2) were missing updated appraisals, three (3) residents (R1, R3 , and R4) did not have proof of annual medical visit or an updated medical assessment, and three (3) residents (R1, R4 and R5) did not have proof of a TB test. During staff file review, LPAs observed five (5) staff files. Of the five (5) staff, three (3) staff (Staff #1 - S1, Staff #2 - S2, Staff #3 - S3) did not have proof of the twenty (20) hours of annual required training. One (1) staff (Staff #4 - S4) did not have the initial forty hours of training. Three (3) staff (S1, S2 and S4) did not have proof of first aid training.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Designees were informed that failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Kelly Dulek
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/22/2026 07:05 PM - It Cannot Be Edited


Created By: Kelly Dulek On 04/22/2026 at 06:04 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: 04/22/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/22/2026
Section Cited
CCR
87303(e)(2)

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87303 (e) (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water....used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
This requirement is not met as evidenced by:
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Designee contacted a plumber, who adjusted the temperatures during today's visit. Water temperatures will be remeasured during a subsequent visit to ensure temperatures remain within range.
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Based on observation, hot water was measured in 6 resident rooms and measured above 120 degrees in 5 rooms, measuring up to 131 degrees and was under 105 degrees in 1 room measuring at 83.4 degrees, which poses an immediate safety risk to persons in care.
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Type B
04/22/2026
Section Cited
CCR87309(a)

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87309 (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions...and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage
This requirement is not met as evidenced by:
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During the visit, housekeeping secured the cart and the memory care staff was called to the common area with the key to lock the drawer. POC cleared.
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Based on observation, a drawer in the memory care unit's common area was left open and contained items such as wound cleanser and personal care items, and housekeeping cart was in the hallway and unlocked, which poses a potential 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: 04/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/22/2026 07:05 PM - It Cannot Be Edited


Created By: Kelly Dulek On 04/22/2026 at 06:26 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: 04/22/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/28/2026
Section Cited
CCR
87506(a)

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87503 (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
This requirement is not met as evidenced by:
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Designee agreed to obtain all identified items for the residents files reviewed. Designee will provide proof of items obtained to CCL by POC due date.
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Based on record review, files were incomplete for all 5 residents reviewed. 3 did not contan proof of annual medical visit or updated medical assessment, 3 did not have proof of TB test, and 2 did not have updated reappraisals, which poses a potential health, safety or personal rights risk.
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Type B
04/28/2026
Section Cited
CCR87411(c)

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87411 (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69

This requirement is not met as evidenced by:
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Designee agreed to properly document all trainings received for all staff and ensure all staff have first aid training. Proof of training will be provided to CCL by POC due date.
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Based on record review, the licensee did not comply with the above cited secton, as staff files did not contain proof of initial training for 1 staff, or annual training for 3 staff, and 3 staff did not have proof of first aid training, which poses a potential health, safety and personal rights 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: 04/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2026


LIC809 (FAS) - (06/04)
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