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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850158
Report Date: 11/02/2022
Date Signed: 11/02/2022 02:48:00 PM


Document Has Been Signed on 11/02/2022 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:AGUINIGA, DAVIDFACILITY TYPE:
740
ADDRESS:903 CARMEN DRIVETELEPHONE:
(805) 586-4191
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:130CENSUS: 53DATE:
11/02/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:28 PM
MET WITH:Monica ReyesTIME COMPLETED:
02:50 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 12:28PM and met with Facility Designee Monica Reyes. LPA explained the reason for today's visit. Entrance interview conducted.

Previously, on 09/27/2022, LPA Dulek had received text message communication from Executive Director David Aguiniga indicating he was leaving his employment at the facility. On 09/30/2022, LPA received a telephone call from Carolina Garcia Trejo indicating she would be acting as Consultant/Administrator for the facility effective on that date. LPA called Licensee Narinder Kumar on 10/07/2022 and left a message regarding the facility Administrator and requested a return call. LPA did not receive a call back. LPA sent an email on 10/07/2022 outlining the necessary timeline and documents to comply with Title 22 requirements. LPA did receive an email message on 10/12/2022 indicating the Consultant/Administrator will contact LPA soon and Consultant/Administrator will comply with the requirements. LPA did not receive a call from the Administrator, but LPA did reach out via telephone to the Consultant during a previous visit at the facility on 10/20/2022. At that time, LPA received a copy of Consultant/Administrator's Administrator Certificate. However to date, LPA still has not received any other paperwork designating Consultant as Acting Administrator. During today's visit, LPA spoke to the Licensee over the phone regarding the Consultant's qualifications, other facilities, and responsibilities. Interview revealed Consultant has not been present in the facility in over a week and is currently acting as Administrator at 2 other large facilities.

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

Exit interview conducted with Designee Monica Reyes, today's reports and appeal rights were provided via email.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2022
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 11/02/2022 02:48 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: 11/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/09/2022
Section Cited

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87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator...shall be on the premises a sufficient number of hours to permit adequate attention... documentation.
This requirement is not met as evidenced by:
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Based on interview and record review, the facility does not have an active Administrator, as the Administrator left before 09/30/2022 and a qualified replacement has not been designated, 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.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2022
LIC809 (FAS) - (06/04)
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