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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850158
Report Date: 10/20/2022
Date Signed: 10/20/2022 04:46:43 PM


Document Has Been Signed on 10/20/2022 04:46 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:AGUINIGA, DAVIDFACILITY TYPE:
740
ADDRESS:903 CARMEN DRIVETELEPHONE:
(805) 586-4191
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:130CENSUS: 55DATE:
10/20/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Monica Reyes, Facility DesigneeTIME COMPLETED:
04:47 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kelly Dulek arrived unannounced to conduct a Case Management – Deficiencies visit at this facility. LPA arrived at 12:00PM and met with Facility Designee Monica Reyes. LPA explained the reason for today's visit. Entrance interview conducted. At 02:07PM, LPA spoke with Facility Consultant/Acting Administrator Carolina Garcia Trejo, who indicated Facility Designee is authorized to sign reports for the facility.

Beginning at 01:07PM, the LPA along with facility Designee toured the physical plant areas inside and outside to ensure there are no health and safety hazards.

At 01:40PM, LPA reviewed the personnel report in the Guardian system. Review of Guardian website revealed Staff #1 (S1) who has been working in the facility since 09/30/2022 has a background clearance, but is not associated to this facility. S1 stated they were unaware they needed to be associated to this facility.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiency was cited (refer to LIC 809-D). Civil Penalties assessed in the amount of $500. Failure to correct the deficiency may result in additional civil penalties.

Exit interview conducted, today's reports and appeal rights were provided via email. Civil penalties issued.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2022
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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Document Has Been Signed on 10/20/2022 04:46 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/21/2022
Section Cited

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)
This requirement is not met as evidenced by:
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Based on interview and record review, the facility did not comply with the above cited section, as S1 has been employed and working at the facility since 09/30/2022 and is not associated to the facility, which poses an immediate 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2022
LIC809 (FAS) - (06/04)
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