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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005550
Report Date: 02/26/2024
Date Signed: 02/26/2024 01:50:20 PM


Document Has Been Signed on 02/26/2024 01:50 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
ORANGE COUNTY RO, 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:
02/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Maryam Alamoutinia, AdministratorTIME COMPLETED:
02:00 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit for the purpose of conducting a Required Annual Inspection. LPA was greeted and granted entry by caregiving staff after introducing himself and stating the purpose of the visit. Administrator Maryam Alamoutinia was contacted by phone and arrived later to assist with the visit.

During the inspection, LPA and administrator conducted a tour of the physical plant and observed the following: The facility is a one-level home with six resident bedrooms, one staff room and three full bathrooms. All resident bedrooms have the required furnishings. LPA observed all beds had linens and blankets and an adequate additional supply is present. The backyard has a shaded sitting area and the route of egress is free of clutter and obstructions. There are currently six residents in care at the facility, none of which are receiving hospice care. Bathrooms faucets and toilets were operational. Water temperature tested at approximately 120F degrees. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged with up-to-date maintenance. Sharps were observed locked in a drawer in the kitchen. LPA observed cleaning supplies to be stored in a locked cabinet under the kitchen sink. The laundry area is also observed to be secured with a lock. The medication central storage was observed to be locked. LPA reviewed six resident files and four staff files.

Based on the observations made during today’s inspection, four type B deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report along with appeal rights was provided to a facility representative.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2024
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 02/26/2024 01:50 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: ASPEN VILLA
FACILITY NUMBER: 306005550

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation made during a tour of the physical plant, the licensee did not comply with the section cited above as neither of the two bathrooms in use to provide toileting care to residents are equipped with slip mats as residents are typically using a shower chair. This however poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2024
Plan of Correction
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Licensee will acquire slipe mats and provide proof of purchase to LPA before the plan of corrections due date.
Type B
Section Cited
CCR
87608(a)
Postural Supports
(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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and records reviewed, the licensee did not comply with the section cited above as one bed was observed to be equipped with full rails in spite of the resident not being on hospice and two other residents' beds have half rails without physician orders on file. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2024
Plan of Correction
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Licensee will proceed to obtain medical orders for half rails for all three residents who require postural supports. Orders will be provided to LPA before the plan of corrections due date.
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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 02/26/2024 01:50 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: ASPEN VILLA
FACILITY NUMBER: 306005550

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.

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 as one resident is being provided oxygen in the absence of any posted signage which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2024
Plan of Correction
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Licensee purchased adequate signage during the visit and will provide LPA with proof of installation prior to the plan of corrections due date.
Type B
Section Cited
CCR
87705(c)(6)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed during the facility visit, the licensee did not comply with the section cited above in one instance as a resident diagnosed with dementia has not been medically assessed since 2021 in spite of the yearly update requirement. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2024
Plan of Correction
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License reached out to the resident's primary care provider during the visit to obtain an updated physician report. Upon completion of the assessment, a copy will be provided to LPA before the plan of corrections due date.
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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3