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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206798
Report Date: 11/03/2021
Date Signed: 11/03/2021 09:58:41 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:ASPEN RESIDENTIAL CARE HOMES INC IIFACILITY NUMBER:
107206798
ADMINISTRATOR:YARBROUGH, SHELLYFACILITY TYPE:
740
ADDRESS:3107 W GETTYSBURG AVETELEPHONE:
(559) 492-2026
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:6CENSUS: DATE:
11/03/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Shelly YarboroughTIME COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct a Case Management visit. LPA met with Administrator Shelly Yarborough and explained the purpose of the visit.


The purpose of the visit is to obtain additional information regarding a Death Report that was received 11/2/21. The facility also self reported R1's death via telephone call to LPA on 11/2/21.

During todays visit, LPA interviewed Administrator and staff (S1). LPA obtained records from Resident's (R1) file.

Administrator agrees to submit the following to LPA by 5PM today: Hospital report (from PCP), S1's internal/facility Incident Report, R1's vitals log dates 10/29 - 10/31/21 and R1's list of medications.


There are no deficiencies cited during this visit
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
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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