366423788-12-11-2023-56-AS-MMAE-CYF27K-20231211160853

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366423788
Report Date: 12/11/2023
Date Signed: 12/11/2023 04:09:12 PM

Document Has Been Signed on 12/11/2023 04:09 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		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:	12/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:54 PM
MET WITH:	Lora Statler, Facility Representative		TIME COMPLETED:	04:15 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, Facility Representative as was granted access to the facility. The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (15) and a current census of (0) residents in care. Facility Representative Statler stated that the facility has not had residents for at least two years. LPA spoke with Administrator, Chris Tanabe, who stated that he wants to keep the facility in operating status although there are no residents in care. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant: LPA observed outdoor frontyard and backyard had overgrown dry shrubs which presents a safety hazards for visitors. LPA spoke with the Administrator who stated that yard maintenance will be conducted at the facility tomorrow. The facility has no pools or other bodies of water. Indoor passageways were free of obstruction. The facility has sufficient indoor and outdoor space for the capacity of residents. Bathroom equipment were in operating condition; however, the facility did not ensure the bathrooms hot water temperature attained at a minimum 105 degrees F. The hot water temperature in (6) bathrooms measured between 54 to 55 degrees F. LPA spoke with the Administrator who stated that he would have the utility company check the water heater.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

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	FACILITY NUMBER: 366423788
	VISIT DATE: 12/11/2023

NARRATIVE

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LPA observed all bedrooms had no beds and no functioning lights. Although, there are no residents in care, the facility should have at a minimum one completely furnished bedroom for visitor and/or licensing inspection.

Care & Supervision: The facility has no staff or residents in care.

Record Review: The facility has no staff or residents in care for record review.

Medical Related Services: The LPA observed a locked room where medications will be kept.

Based on LPA observations, deficiencies 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 provided to the facility representative with Appeal Rights 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: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/11/2023 04:09 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	FACILITY NUMBER: 366423788
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Maintenance and Operation


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Type B

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). 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 not ensuring the bathrooms hot water temperature attained at a minimum 105 degree F, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/05/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator shall submit to the licensing agency proof of correction 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: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

LIC809 (FAS) - (06/04)

Page: 3 of 8

Document Has Been Signed on 12/11/2023 04:09 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	FACILITY NUMBER: 366423788
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(a)(3)(B)

Personal Accommodations and Services

(B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. 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 not ensuring the facillty has at a minimum one completely furnished bedroom, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/05/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator has submit to the Licensing Agency proof of completely furnished bedroom by POC due date

Type B

Section Cited

CCR

87307(d)(2)

Personal Accommodations and Services

(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. 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 frontyard and backyard of the facilty had overgrown dry shrubs, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/05/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator shall submit to the licensing agency proof of yard maintenance 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: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

LIC809 (FAS) - (06/04)

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