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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423704
Report Date: 02/17/2022
Date Signed: 02/17/2022 01:52:07 PM


Document Has Been Signed on 02/17/2022 01:52 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:AASPEN VILLAGECARE IIFACILITY NUMBER:
366423704
ADMINISTRATOR:MUSHTAQ KHANFACILITY TYPE:
740
ADDRESS:7645 KICKAPOO TRAILTELEPHONE:
(760) 365-6338
CITY:YUCCA VALLEYSTATE: CAZIP CODE:
92284
CAPACITY:15CENSUS: 12DATE:
02/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Christopher TanabeTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 02/17/2022 at 10:00 AM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with House Manager Patricia Roggenbuck and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Administrator Christopher Tanabe was contacted and later arrived during the visit. Below is a summary of what was observed:

Infection Control: LPA Brown went over COVID-19 best practices for infection control and prevention with House Manager Roggenbuck and Adinistrator Tanabe and they reported that Mitigation Plan was submitted January 2021. LPA Brown requested Administrator Tanabe to send a copy of Mitigation Plan via email.

LPA Brown observed the facility having Covid-19 signages throughout the facility for proper hand washing procedure, social distancing. LPA Brown toured the facility's resident bedrooms and bathrooms and observed that both resident bathrooms have paper towels and hand soap. LPA Brown requested to inspect the facility's Personal Protective Equipment (PPE) supply. LPA Brown observed the facility to have a sufficient supply of sanitizer, gloves, masks, and face shields/goggles or isolation gowns. LPA Brown went over the various recommended training for facility staff with Administrator Tanabe in relation to COVID-19 and informed Administrator Tanabe staff needs to be trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE.

LPA Brown inquired as to if staff have been fit tested for N95 masks, and Administrator Tanabe informed LPA Brown that at this time staff have not been fit tested. LPA Brown will be issuing a deficiency during today's inspection for staff not being fit tested for N95 masks. LPA Brown will be issuing a deficiency for this item due to the facility just had COVID-19 positive resident last month, and N95 masks needs to be *** Continuation in LIC809C ***
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022
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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: AASPEN VILLAGECARE II
FACILITY NUMBER: 366423704
VISIT DATE: 02/17/2022
NARRATIVE
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worn when a resident is COVID-19 positive or under observation while awaiting test results. Additionally, most residents and staff have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. LPA Brown will be providing Administrator Tanabe with the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.

The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and their residents for COVID-19, when and how to isolate/quarantine residents, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor their residents regularly for any changes in condition and to subsequently notify the resident's physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

During the visit, Administrator Tanabe handed LPA Brown copies of Emergency Care Requirements, and LPA Brown instructed Administrator Tanabe to post it in the Bulletin Board. In the process of conducting the annual inspection, LPA Brown discovered that the facility allowed one (1) caregiver, Staff 1 (S1) to work at this facility without fingerprint clearance. It appears that S1 have been allowed to work at the facility since 10/30/2021. Although Administrator Tanabe reported that S1 was sent to get fingerprint cleared, per records review, the criminal background clearance is still pending and there is no proof provided that S1 was cleared to be allowed to work at the facility. Therefore, this facility will be cited for civil penalties. Also, during the tour of the inside and outside of the facility, LPA Brown observed four (4) window screen doors in disrepair. LPA Brown will be issuing a deficiency for not having the windows screen in good repair.

An exit interview was conducted with Administrator Christopher Tanabe and a copy of this report (LIC809), LIC 809D's, LIC421BG and Appeal Rights were discussed and provided.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/17/2022 01:52 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: AASPEN VILLAGECARE II
FACILITY NUMBER: 366423704

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(13)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by allowing Staff 1 to work at the facility without criminal background clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/18/2022
Plan of Correction
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Administrator immediately removed Staff 1 (S1) at the the facility during the visit.
Administrator stated he will submit Statement of Understanding on CCR 87412(a)(13) and submit to LPA Brown by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4

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: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 02/17/2022 01:52 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: AASPEN VILLAGECARE II
FACILITY NUMBER: 366423704

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not maintaining four (4) window screens in good repair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2022
Plan of Correction
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Administrator stated that they will repair and put back the four (4) window screens and submit prrof of correction to LPA Brown by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4

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: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 02/17/2022 01:52 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: AASPEN VILLAGECARE II
FACILITY NUMBER: 366423704

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
30
Licensee has provided all staff who are working with Covid-19 positive residents with fit testing for N95 respirators. This practice has a health and safety impact, that includes but is not limited to personal rights, buildings and grounds and responsibility for providing care and supervision.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by not having all staff fit tested for N95 respiratorswhich poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2022
Plan of Correction
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Administrator stated that they will have all staff N95 fit tested and submit proof of completion to LPA Brown by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4

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: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5