366423788-7-2-2021-18-AS-JESL-CG8VD2-20220711162000

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366423788
Report Date: 07/02/2021
Date Signed: 07/02/2021 12:31:48 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/10/2020 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20201210141038

FACILITY NAME:	AASPEN VILLAGECARE		FACILITY NUMBER:	366423788
ADMINISTRATOR:	MUSHTAQ KHAN		FACILITY TYPE:	740
ADDRESS:	7633 KICKAPOO TRAIL		TELEPHONE:	(760) 365-8300
CITY:	YUCCA VALLEY	STATE: CA	ZIP CODE:	92284
CAPACITY:	15	CENSUS: 0	DATE:	07/02/2021
		UNANNOUNCED	TIME BEGAN:	11:47 AM
MET WITH:	Administrator Christopher Tanabe		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility has rodents.
Facility is malodorous.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegation(s) listed above. LPA was greeted and granted entry by Caregiver Cassandra Loe. LPA George identified herself and discussed the purpose of the visit and the elements of the allegation(s) with Administrator Christopher Tanabe whom arrived a few minutes later after LPA. The investigation consisted of a review of pertinent documentation and interviews.

Allegation: Facility has rodents.
On 12/14/20 LPA George conducted a tour of the physical plant and observed the following: black box (traps), outside of the facility once inside LPA observed droppings inside the hallway where the backup refrigerator and food is stored. LPA conducted a search inside of the cabinets and did not observe any droppings, however staff was hitting on the cabinets before opening them and stated that, “that is where the rodents (rats, and mice) were”. In addition, LPA reviewed documentation that revealed rodents running around inside * Continued on 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20201210141038

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/02/2021

NARRATIVE

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and outside of the facility. On one occasion there were 5 rats and or mice grabbing food (slice of bread) outside of a black trash bag that was sitting in front of the facility by the gate. LPA interviewed Administrator Christopher whom stated that due to the infestation all the residents had been temporarily relocated to one of the Sister facility Aaspen Village care II #366423704. Based on observation, interview and record review the allegation of Facility has rodents is SUBSTANTIATED. This posed an immediate health and safety risk to residents in care.

Allegation: Facility is malodorous
On 12/14/20 LPA conducted a tour of the physical plant. Upon entry of the facility front door was an overwhelming odor, that is associated with deceased rodents. As a result, all residents had to be temporarily relocated to one of the Sister facility Aaspen Village care II #366423704. Interviews conducted and the feedback provided was the odor is overwhelming unhealthy and can make you sick and that the only reason why staff are still entering the facility is to get food out of the refrigerator. Based on observations and interview the allegation of Facility is malodorous is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. This posed an immediate health and safety risk to residents in care.

An exit interview was conducted and a copy of this report and appeal rights was provided to Administrator Christopher Tanabe.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20201210141038

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/02/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/03/2021 Section Cited HSC 1569.269(a)	1 2 3 4 5 6 7	1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (5) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. Based on observation, interview and record review this requirement is not met as evidenced by: on 1 out of 1 times the resident’s were not accorded safe, healthful, and comfortable accommodations due to the rodent infestation. This poses an immediate health and safety risk to persons in care.	1 2 3 4 5 6 7	The licensee agrees to have the residents relocated to the sister facility until the infestation has been eliminated. The licensee will also have the exterminator come and treat the facility as they recommend, the licensee will submit copies of the invoices to department 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	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021

LIC9099 (FAS) - (06/04)

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