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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206797
Report Date: 07/29/2021
Date Signed: 07/29/2021 12:29:56 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/03/2020 and conducted by Evaluator Kelly J. McClurg
COMPLAINT CONTROL NUMBER: 24-AS-20200803085757
FACILITY NAME:ASPEN RESIDENTIAL CARE HOMES INC IFACILITY NUMBER:
107206797
ADMINISTRATOR:DAVIS, JERRY WFACILITY TYPE:
735
ADDRESS:4468 N HAZEL AVETELEPHONE:
(559) 492-2026
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:6CENSUS: 6DATE:
07/29/2021
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Licensee Shelly YarbroughTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility unsafe environment resulted in resident sustaining injury.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
A Complaint visit was conducted on the date & times indicated above by Licensing Program Analyst (LPA) K. Mcclurg. LPA met with Licensee (LIC) Shelly Yarbrough. LPA reviewed the purpose of the visit LIC.

The Department reviewed facility records & conducted interviews with facility personnel. The Department has investigated the above allegation & have determined it to be unsubstantiated

No deficiencies issued.
Exit interview conducted with LIC. Report Provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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