366423788-9-5-2023-18-AS-TDAN-DAJL7V-20241030083056

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366423788
Report Date: 09/05/2023
Date Signed: 09/05/2023 11:43:27 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/19/2021 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210519091918

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:	09/05/2023
		UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Lora Statler, House Manager		TIME COMPLETED:	11:21 AM

ALLEGATION(S):

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Neglect of resident in care

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 noted above. LPA met with Lora Statler, House Manager. Administrator Christopher Tanabe was available via telephone. and explained the purpose of the visit and the elements of the allegation. The allegation was investigated, the investigation consisted of observation, interviews and record review.

It was alleged that on or around May 18, 2021, Resident #1 (R1) was neglected by facility staff. R1 was reported to have been observed found with flies on their body, covered in blood, wound dressing missing, dried feces and blood on body, blankets covered in blood, finger covered in blood, eye crusts formed, and disheveled bedding. LPA reviewed resident observation logs dated May 17, 2021, R1 is noted to have had a bed bath, as well as their bedding changed. On May 18, 2021, revealed that R1 would pick the sores and heavily bleed as well as remove the dressing that was located on their right ear. The facility observation log notes that staff had to change, and clean R1 as they were observed to have blood on their fingers that were covered in blood. Further documentation dated May 18, 2021 further

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023

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-20210519091918

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: AASPEN VILLAGECARE	FACILITY NUMBER: 366423788
	VISIT DATE: 09/05/2023

NARRATIVE

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documentation reviewed revealed staff reporting that R1’s gown and comforter had drops of blood, along with blood being collected on the chuck and soiled dressing on R1’s right ear, and that hospice was contacted to assist and change the dressing.

R1 is noted on May 19, 2021, R1 had a visit with from the hospice agency staff who had provided wound care for R1 including have covered the wound on the right ear with a dressing/gauze. Per the facility observation logs 30 minutes after hospice left, R1 was noted to have removed their dressing again. The observation logs notes that facility staff contacted R1’s hospice agency at 12:05pm and was informed that they would send someone out. Facility staff is noted to having called the Administrator as hospice had not shown up as of 2:10pm, also noting that most of the blood was cleaned up. LPA conducted a physical visit to the facility on May 21, 2021. LPA did not observe any flies, in R1s room or flying around the facility. R1 was observed to be sleeping and noted to have clean bedding and clothing. LPA was unable to interview R1, due to them being asleep, and reported to be transitioning. R1 did not wake up at any point, during the time of LPAs visit. Per staff interviews conducted revealed that staff denied the allegation and stated that it has been an ongoing occurrence with R1 picking at their wound and removing the dressing, and that the bedding is changed as often as it is needed, as a result of the wound picking. Based on observation, interviews and record review the allegation of neglect of resident in care is UNFOUNDED. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

An exit interview was conducted and a copy of this report was provided to Lora Statler, House Manager.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023

LIC9099 (FAS) - (06/04)

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