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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881025
Report Date: 03/21/2024
Date Signed: 03/21/2024 02:46:42 PM


Document Has Been Signed on 03/21/2024 02:46 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:ASPEN GROVE HOME CAREFACILITY NUMBER:
361881025
ADMINISTRATOR:ENCIU, OLGAFACILITY TYPE:
740
ADDRESS:1220 N. DEARBORN STREETTELEPHONE:
(310) 721-4441
CITY:REDLANDSSTATE: CAZIP CODE:
92374
CAPACITY:6CENSUS: 5DATE:
03/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Olga Enciu - AdministratorTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Olga Enciu, Administrator, and discussed the purpose of the visit.

The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (6), a current census of (5) residents in care, a hospice waiver for (2). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility has no swimming pools or similar bodies of water. Outdoor shaded area is sufficient for resident activities and is enclosed with a self-latching gates.The facility has sufficient lighting and is maintained at a comfortable temperature. Resident’s showers, toilets, and hand washing areas were operating in a safe and sanitary condition. The hot water temperature in residents' bathrooms measured 109 degrees F. The facility's (5) resident bedrooms had beds, bed linen, nightstands, chairs, and sufficient lighting. The facility has operating carbon monoxide alarms, telephone service, and laundry equipment. The facility has sufficient linen, towels, and personal hygiene items for residents. The facility has posted in a common area, Community Care Licensing complaint poster, Ombudsman poster, evacuation exit plan, and emergency telephone numbers. Sharps, disinfectants, and cleaning solutions were kept locked and inaccessible to residents in care.
Food Service: Facility kitchen and dining areas are maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care. The facility has sufficient plates, cups, and utensils for resident use.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
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 6


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ASPEN GROVE HOME CARE
FACILITY NUMBER: 361881025
VISIT DATE: 03/21/2024
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Care & Supervision: Facility has 24-hour, 7 days a week direct care staff.

Medical Related Services: The facility has a complete first aid kit. Resident’s medications are labeled and centrally stored in a locked cabinet.

Record Review: The facility's Administrator’s certification and liability insurance are current. Staff files reviewed were observed to be complete. LPA review of (5) resident files reveals, resident #1 (R1) and resident #2 (R2) did not have a current annual physician's report/medical assessment on file as required based on their cognitive diagnosis. LPA review of facility files reveals, the facility did not have documentation of emergency drill conducted with staff on file for review. Deficiencies cited.

Based on observations and record review, deficiencies are being cited per Title 22, of The California Code of Regulations and Health and Safety Codes.

This report was reviewed with the Administrator and a copy with Appeal Rights was provided to the Administrator at the conclusion of the visit.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 03/21/2024 02:46 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: ASPEN GROVE HOME CARE
FACILITY NUMBER: 361881025

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA records review, the licensee did not comply with the section cited above by the facility did not have documentation of emergency drill conducted with staff on file for review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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The Licensee shall submit to the Licensing Agency documentation of current drill with a list of staff participants by POC due date.
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above in by resident #1 (R1) and resident #2 (R2) did not have a current annual physician's report/medical assessment on file as required based on their cognitive diagnosis; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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The Licensee shall submit to the Licensing Agency documentation of annual physician's report for R1 and R2 by POC 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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
LIC809 (FAS) - (06/04)
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