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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423788
Report Date: 05/21/2021
Date Signed: 05/21/2021 11:25:51 AM

Document Has Been Signed on 05/21/2021 11:25 AM - 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 VILLAGECAREFACILITY NUMBER:
366423788
ADMINISTRATOR:MUSHTAQ KHANFACILITY TYPE:
740
ADDRESS:7633 KICKAPOO TRAILTELEPHONE:
(909) 263-7547
CITY:YUCCA VALLEYSTATE: CAZIP CODE:
92284
CAPACITY: 15CENSUS: 8DATE:
05/21/2021
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Administrator Christopher TanabeTIME COMPLETED:
11:33 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Javina George and Yolanda Delgado conducted a case management deficiency visit. LPAs George and Delgado identified themselves, and explained the purpose of the visit. LPAs were greeted and granted entry by caregiver Rebecca Phipps. At the time of the visit there were 2 staff present, and 8 residents at the facility. The administrator Christopher Tanabe

All residents were observed to be in their rooms asleep, and or watching TV and eating.
The facility was clean and odor free. The facility has a 2 day of perishables and a 7 day supply of nonperishable food items.

LPAs George and Delgado observed that Staff # 1 (S1) and staff # 2 (S2) providing care were not be associated to the facility. Therefore, a deficiency will be cited and immediate civil penalties of $1000 will be assessed.

An exit interview was conducted via telephone with Administrator Christopher, and a copy of this report, 9099D, and LIC421BG appeal rights were provided to Rebecca to provide to Administrator upon his arrival.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2021
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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Document Has Been Signed on 05/21/2021 11:25 AM - It Cannot Be Edited


Created By: Javina George On 05/21/2021 at 10:47 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: AASPEN VILLAGECARE
FACILITY NUMBER: 366423788

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/04/2021
Section Cited
HSC
80019(e)(1)

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80019 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department or... This requirement is not met as eveidenced by:
The Licensee did not ensure that at least 2 out of 2 staff were associated to the facility.
Based on observation, interview, and record review this poses a potential health, safety and personal rights risks to persons in care.
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The licensee or Administrator will use the Guardian system and will associate both staff to the facility by 5pm, on the due date indicated.

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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:Joel Esquivel
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2021


LIC809 (FAS) - (06/04)
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