366423704-12-18-2023-56-AS-MMAE-CYN2JD-20231218162610

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366423704
Report Date: 12/18/2023
Date Signed: 12/18/2023 04:26:26 PM

Document Has Been Signed on 12/18/2023 04:26 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:	AASPEN VILLAGECARE II		FACILITY NUMBER:	366423704
ADMINISTRATOR:	MUSHTAQ KHAN		FACILITY TYPE:	740
ADDRESS:	7645 KICKAPOO TRAIL		TELEPHONE:	(760) 365-6338
CITY:	YUCCA VALLEY	STATE: CA	ZIP CODE:	92284
CAPACITY:	15	CENSUS: 9	DATE:	12/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Lora Statler, House Manager		TIME COMPLETED:	04:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Lora Statler, House Manager and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (15) and a current census of (9) residents in care. The facility has a hospice waiver for (6) residents. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant: Indoor and outdoor passageways are free of obstruction. The facility has no bodies of water accessible to residents in care. Outdoor area is fenced and sufficient for resident activities. The facility has sufficient lighting and is maintained at a comfortable temperature. Resident’s bathrooms were operating in safe and sanitary conditions. The hot water temperature in residents' bathrooms measured between 105 to 112 degrees F. Resident’s bedrooms have sufficient lighting and furniture in good repair. Facility has operating carbon monoxide alarms and telephone service. The facility has sufficient linen, towels, and personal hygiene items for residents. The facility has posted: facility license, Ombudsman poster, "Oxygen in use" signs, disaster evacuation plan and emergency telephone numbers.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: AASPEN VILLAGECARE II	FACILITY NUMBER: 366423704
	VISIT DATE: 12/18/2023

NARRATIVE

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Food Service: Facility has sufficient non-perishable and perishable food supply for residents in care. The refrigerators and freezers are operating in a healthful manner. Sharps, pesticides and other cleaning solutions were kept locked and stored away from food areas.

Care & Supervision: Facility has 24-hour/7 days a week care staff.

Record Review: The last emergency drill was conducted on 12/13/23. Administrator’s certification expires on 4/14/2024. LPA review of staff files reveal, the facility did not maintain record of CPR training for staff #2 (S2), staff #3 (S3), and staff#4 (S4). The facility did not maintain a criminal background clearance and health screening for staff#1(S1). LPA review of resident files reveal, resident #1 (R1) had an incomplete residential appraisal on file. LPA facility record review reveals, the facility did not maintain record of liability insurance.

Medical Related Services: All medication is centrally stored and kept locked.

Based on LPA observations and record review, deficiencies and civil penalties are being cited per Title 22, Division 6 of The California Code of Regulations.

An exit interview was conducted where reports (LIC809/LIC809-D/LIC9102) were discussed and copies with Appeal Rights were provided to the House Manager at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/18/2023 04:26 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: AASPEN VILLAGECARE II	FACILITY NUMBER: 366423704
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87412(a)(13)(B)

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: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review, the licensee did not comply with the section cited above by staff #1 did have have record of criminal record clearance by the department, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/19/2023
	Plan of Correction
1 2 3 4	The licensee/Administrator shall submit to the Licensing agency by POC due date, a statement of understanding on regulation cited and an understanding that uncleared staff shall not return to the facility until staff has received a criminal record clearance.

Section Cited

Criminal Record Clearance


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/18/2023 04:26 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: AASPEN VILLAGECARE II	FACILITY NUMBER: 366423704
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.605

Other Provisions

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations and interviews, the licensee did not comply with the section cited above by facility did not maintain record of liability insurance , which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/12/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator shall submit to the licensing agency proof of insurance by POC due date.

Type B

Section Cited

CCR

87457(c)

Pre-Admission Appraisal

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above by resident #1 did not have a complete appraisal on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/12/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator shall submit to the licensing agency proof of completed resident appraisal 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 Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/18/2023 04:26 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: AASPEN VILLAGECARE II	FACILITY NUMBER: 366423704
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review, the licensee did not comply with the section cited above by LPA review of staff files reveal, the facility did not maintain record of CPR training for staff #2 (S2), staff #3 (S3), and staff#4 (S4) CPR, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/12/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator shall submit to the Licensing Agency record of staff CPR/first aid training.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/18/2023 04:26 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: AASPEN VILLAGECARE II	FACILITY NUMBER: 366423704
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician...This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above facility did not maintain record of staff #1's health screening, did not have recordswhich poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/12/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator shall provide proof of staff#1 health screening with tuberculosis results by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023

LIC809 (FAS) - (06/04)

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