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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005550
Report Date: 09/15/2021
Date Signed: 09/15/2021 02:11:54 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ASPEN VILLAFACILITY NUMBER:
306005550
ADMINISTRATOR:ALAMOUTINIA, MARYAMFACILITY TYPE:
740
ADDRESS:25911 VIA VIENTOTELEPHONE:
(949) 648-9205
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
09/15/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:02 PM
MET WITH:Administrator Maryam AlamoutiniaTIME COMPLETED:
02:25 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Albert Marin and Beverly Thompson-Gracia made an unannounced visit to this facility to conduct a case management visit to discuss the Coronavirus 2019 (COVID 19) mitigation plan of the facility. Via phone, LPA Marin spoke with Administrator (AD) Maryam Alamoutinia and stated the purpose of this visit.

About 12:05 PM, LPAs Marin and Gracia were granted entry in the facility after completing the COVID 19 screening procedures. LPAs toured the interior and exterior portions of the facility and observed six residents in care and two staff members on the floor. After the tour, LPAs reviewed the COVID 19 mitigation plan of the facility on file; and discussed Provider Information Notice (PIN) 21-38-ASC: Updated Guidance for the Use of Face Masks, Surgical Masks and Respirators Related to Coronavirus Disease After the discussion, LPA Gracia left the facility.

About 12:23 PM, LPA Marin requested and reviewed staff records which included by not limited to personnel records, criminal background clearances and staff training. LPA observed that Staff 2 had to criminal background clearance on file. LPA called AD Alamountia about the observation. AD arrived in the facility shortly thereafter. LPA Marin reviewed the staff files with AD. LPA observed fingerprint scan request was filled up but was not completed.

For this visit, deficiency was observed; and citation was issued per Title 22 Division 6 of the California Code of Regulations.

LPA Marin conducted and exit interview with AD Alamoutinia. LPA discussed the deficiency, citation, assessment of civil penalty and appeal rights with AD. Copies of this report, LIC809 (Deficiency), Confidential Names, Civil Penalty Assessment form, cited regulation and PIN 21-38-ASC were left in the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ASPEN VILLA
FACILITY NUMBER: 306005550
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/16/2021
Section Cited

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87411 Personnel Requirements - General. Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:Obtain a California clearance or a criminal record exemption as required by law or Department regulations.. This requirement was not met as evidenced by:
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Based on file review and interview, the Facility missed to ensure that employee obtained a California clearance prior to employment. As verified with Administrator (AD), Staff 2 did not have a California criminal record clearance on file prior to employment. Hire date was April 17, 2021. This posed immediate threat on the safety the residents in care.
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AD will provide copy of the clearance to Community Care Licensing Division (CCLD) as soon as the document becomes available or before 5:00 PM of 09/24/2021.

Civil penalty was assessed.

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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: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2021
LIC809 (FAS) - (06/04)
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