366423788-2-17-2022-18-AS-MBRN-CBQUBY-20220217142706

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366423788
Report Date: 02/17/2022
Date Signed: 02/17/2022 02:27:13 PM

Document Has Been Signed on 02/17/2022 02:27 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		FACILITY NUMBER:	366423788
ADMINISTRATOR:	MUSHTAQ KHAN		FACILITY TYPE:	740
ADDRESS:	7633 KICKAPOO TRAIL		TELEPHONE:	(909) 263-7547
CITY:	YUCCA VALLEY	STATE: CA	ZIP CODE:	92284
CAPACITY:	15	CENSUS: 0	DATE:	02/17/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Christopher Tanabe		TIME COMPLETED:	02:45 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) 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 Administrator 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 inside and outside the facility and observed that there's no resident at the moment but Administrator Tanabe reported that they will have resident soon at the facility. LPA Brown observed resident bedrooms and bathrooms with 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 that once they have residents at the facility, staff needs to be trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE. Also, LPA Brown informed Administrator Tanabe that once they'll have residents, all staff need to be fit tested for N95 masks. * Continuation in LIC809C *

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 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	FACILITY NUMBER: 366423788
	VISIT DATE: 02/17/2022

NARRATIVE

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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.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted with Administrator Christopher Tanabe and a copy of this report (LIC 809) was discussed and provided.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 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)

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