366424198-4-14-2023-56-AS-KCLS-CT3PSU-20230623113456

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366424198
Report Date: 04/14/2023
Date Signed: 04/14/2023 12:56:26 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
04/12/2023 and conducted by Evaluator Magda Malcore

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230412104800

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: 14	DATE:	04/14/2023
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Amanda Roberts (Tucker) ,House Manager		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Unlawful eviction

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced complaint visit to the facility. LPA met with Amanda Robert (Tucker). Licensee was not at the facililty at the time of the visit, LPA contacted Administrator Christopher Tanabe by telephone and discussed the purpose of the visit.

LPA conducted interviews with facility staff, resident #1 (R1), outside parties, obtained and reviewed facility file documents. R1 was sent the hospital due to a fall and then transferred to a nursing facility. R1 was discharged back to facility residence on 4/11/23. Upon R1s return to the facility residence, a staff member informed R1s driver that the resident could not return back into the facility and R1 had to be transported back to the nursing facility. Interview with the Administrator admitted that they refused to take R1 back into the facility residence due to the facility is unable to provide a higher level of care for R1. R1 is currently still at the nursing facility awaiting to be transported back to the facility residence.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

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 56-AS-20230412104800

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 VILLAGE CARE III	FACILITY NUMBER: 366424198
	VISIT DATE: 04/14/2023

NARRATIVE

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The licensee did not follow Title 22 Regulation procedures on evictions by refusing to allow R1 into the facility residence; this poses a potential health and safety risk to residents in care.

Based on file review and LPA’s interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated per California Code of Regulations, Title 22, Division 6. Deficiency is being cited on the attached LIC9099D.

An exit interview was conducted where these reports (LIC9099 and LIC9099D) and appeal rights were discussed and provided to the Ashley Roberts (Tucker).

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20230412104800

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 VILLAGE CARE III	FACILITY NUMBER: 366424198
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/14/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/17/2023 Section Cited CCR 87468.2(a)(20)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights… (a)In addition…residents…rights(20) To be protected from involuntary transfers, discharges, and evictions. A licensee …shall comply with…eviction and relocation protection for residents, this requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee to accept resident (R1) back into the facility. Licensee to review section cited and 87224 Eviction procedures and submit a statement of understanding by POC date.
	8 9 10 11 12 13 14	On 04/11/23, R1 was discharged from the hospital and the licensee refused R1 back into the facility due the facility is unable provide a higher level of care for R1.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC9099 (FAS) - (06/04)

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