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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206798
Report Date: 09/16/2024
Date Signed: 09/16/2024 12:25:27 PM


Document Has Been Signed on 09/16/2024 12:25 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, 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: 6DATE:
09/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:34 AM
MET WITH:Shelly Yarbrough.
TIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the Annual Inspection. LPA met with and explained the reason for the visit with Administrator (AD) Shelly Yarbrough.

During this visit, LPA toured the facility inside & out. Resident rooms and common areas were clean, in good repair and contained required furnishings and lighting. LPA observed required items in bathrooms with hot water measuring within required limits. LPA observed hygiene items, towels, extra bedding, and linens which were stored and available for use. The kitchen was observed to be clean, in good repair with necessary items and appliances. LPA observed required food supply and paper products. Knives, cleaning/disinfecting supplies and chemicals were locked are stored separate from food. Doors and passageways are unobstructed throughout the facility including outdoors. Medications are centrally stored and locked. A First aid kit contained required items. Facility has multiple visitation and common areas available. LPA walked the outdoor areas to find the grounds well-kept with walkways and sitting areas. Fire extinguishers were serviced and charged on 10/23/23 by Valley Fire Co. Smoke and carbon monoxide detectors were tested and working properly. LPA conducted resident and staff file reviews, P&I and medication audits. Required postings were observed throughout the facility. Emergency Disaster and Infection Control Plans were reviewed during the inspection.

Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D in the areas of: Postural Supports and Personal Accommodations and Services

An exit interview was conducted and Plan of Correction (POC) developed. A signed copy of this report and Appeal Rights were provided.



See LIC809C for continuation of this report
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 II
FACILITY NUMBER: 107206798
VISIT DATE: 09/16/2024
NARRATIVE
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LPA requested the following updated forms faxed to CCLD by 10/16/24: Designation of Facility
Responsibility (Lic308), Administrative Organization (Lic309), Affidavit Regarding Client/Resident Cash Resources (LIC 400), Surety Bond (Lic402), Emergency Disaster Plan LIC610D, Personnel Report (LIC 500), Client Roster (LIC 9020), Proof of current Liability Coverage, Infection Control Plan (6/22).
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/16/2024 12:25 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, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: ASPEN RESIDENTIAL CARE HOMES INC II
FACILITY NUMBER: 107206798

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(e)
87307(e) Personal Accommodations and Services (e) Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools, or similar bodies of water, when not in active use by residents, through fencing, covering or other means.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. LPA observed the side yard gate did not have a lock.
POC Due Date: 09/17/2024
Plan of Correction
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DEFICIENCY CLEARED during the visit. AD immediately placed a lock on the side yard gate which opens to the pool.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 09/16/2024 12:25 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, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: ASPEN RESIDENTIAL CARE HOMES INC II
FACILITY NUMBER: 107206798

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(2)
Postural Supports
87608 (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (2) Postural supports shall be fastened or tied in a manner that permits quick release by the resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care. AD has agreed to have R1 evaluated for a different postural support that R1 can self release.
POC Due Date: 10/16/2024
Plan of Correction
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AD has agreed to have R1 evaluated for a different postural support that R1 can self release. A written statement will be submitted which includes the plan for R1's postural support based on the assessment by poc date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4