366424198-4-27-2021-18-AS-JGEE-C2GVM9-20210427163310

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366424198
Report Date: 04/27/2021
Date Signed: 04/27/2021 04:33:21 PM

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 VILLAGE CARE III		FACILITY NUMBER:	366424198
ADMINISTRATOR:	MUSHTAQ KHAN		FACILITY TYPE:	740
ADDRESS:	56524 ANTELOPE TRAIL		TELEPHONE:	(760) 369-9294
CITY:	YUCCA VALLEY	STATE: CA	ZIP CODE:	92284
CAPACITY:	23	CENSUS: 15	DATE:	04/27/2021
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Administrator Christopher Tanabe		TIME COMPLETED:	12:10 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) Javina George conducted an unannounced virtual health and safety check via facetime due to COVID-19. It was reported that the facility currently does not have any hot water. LPA met with Administrator Christopher (Chris) Tanabe and explained the purpose of the visit. Administrator explained that the facility does have hot water it was turned off due to there being detected in the hot water supply. However, after attempts by the maintenance man, and plumber there was no success to pin point the exact location of the leak. Chris stated that the plumber provided a referral for a company specializing in leak detection. Chris stated that the company is due to come out to the facility tomorrow 4/28/21 between 8am and 10am, to locate the leak and repair it. LPA Inquired as to when the facility staff became aware of the leak, Administrator stated on 4/21/21. The department was not notified of the incident, and a deficiency will be cited. At 11:29am LPA observed during the tour of the exterior of the facility part of the ground to have been dug up and pipes exposed. Administrator explained the location of one leak that had been repaired in the small pipe and the attempts that have been made to resolve the issue. LPA conducted interviews with staff and resident's. During interviews it was determined that the resident's had not had a shower or been able to use the shower at minimum in at a week and a half. LPA inquired as to how the residents 1 and 2 (R1, R2) were being cleaned, R1 stated that they ask staff to warm up water in the microwave and they have a sponge bath. R2 stated that they had been using wipes or whatever they find. A deficiency will be cited. At 11:52am LPA observed an oversized silver pot, full of water on the stove. LPA asked Staff #1 (S1) what it was going to be used for.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021

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

LIC809 (FAS) - (06/04)

Page: 1 of 3

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 VILLAGE CARE III	FACILITY NUMBER: 366424198
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/27/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/28/2021 Section Cited	1 2 3 4 5 6 7	80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met by: Based on observation, interview and record review the licensee did not ensure that the leak was repaired in a timely manner This poses an immediate Health, Safety or Personal Rights risk to persons in care.
Type B 05/11/2021 Section Cited	1 2 3 4 5 6 7	80061 Reporting Requirements Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
	8 9 10 11 12 13 14	This requirement is not met by: Based on observation, interview and record review the licensee did not notify the department about the leak. This poses a potential Health, Safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7

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: 04/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

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 VILLAGE CARE III	FACILITY NUMBER: 366424198
	VISIT DATE: 04/27/2021

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
26
27
28
29
30
31
32

S1 stated that they needed to wash the dishes that were used during lunch. LPA inquired if that is how the dishes were being washed since the leak began, S1 replied "yes".

LPA asked S1 to turn on the faucet in the kitchen sink, LPA observed the left side (hot water) to have a low stream coming out as to where the right side (cold water) had full power. During interviews LPA inquired as to what happens when the shower located in the bathroom in room # 11. The response was that the bathroom and bedroom begins to flood with water.

Based on today's inspection, deficiencies were observed in the areas evaluated and cited according to California Code of Regulations, Title 22, Division 6 and listed on the LIC 809D.

An exit interview was conducted and a copy of this report, 809C, 809D, and appeal rights were 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: 04/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3