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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366424198
Report Date: 08/18/2023
Date Signed: 08/18/2023 11:48:51 AM


Document Has Been Signed on 08/18/2023 11:48 AM - 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 VILLAGE CARE IIIFACILITY NUMBER:
366424198
ADMINISTRATOR:MUSHTAQ KHANFACILITY TYPE:
740
ADDRESS:56524 ANTELOPE TRAILTELEPHONE:
(760) 369-9294
CITY:YUCCA VALLEYSTATE: CAZIP CODE:
92284
CAPACITY:23CENSUS: 13DATE:
08/18/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Amanda Roberts, House ManagerTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Magda Malcore conducted a case management visit based on deficiency observed during complaint investigation #56-AS-20230227155936. LPA met with Amanda Roberts, House Manager and discussed the purpose of the visit.

LPA review of staff records reveal Staff #1 (S1) does not have the proper background clearance. LPA determined through Guardian system records that S1 did not have a criminal record clearance and application was closed in 2021. Facility personnel report shows S1’s start date as 9/20/2021. Civil penalties are being accessed today for not ensuring staff had proper clearance or exemption prior to working for the facility.

A exit interview was conducted and a copy this report with appeal rights was provided to the House Manager at the conclusion of the visit.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2023
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 2


Document Has Been Signed on 08/18/2023 11:48 AM - 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 VILLAGE CARE III
FACILITY NUMBER: 366424198

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/19/2023
Section Cited
CCR
87355(e)(1)

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87355 Criminal Record Clearance (e) all individuals subject to criminal record review…shall prior to working…in a licensed facility: (1) obtain California Clearance or a criminal record exemption as required by the Department...This requirement is not met as evidenced by:
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Administrator shall submit a letter of understanding of regulation cited and understanding that staff shall not return to the facility until staff has been cleared to the licensing agency by POC date.
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Based on interviews and record review, the licensee did not ensure a criminal record clearance was obtained for Staff #1 (S1) prior to working at the facility, which poses an immediate Health, Safety, or Personal Rights risks to persons in care.
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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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2023
LIC809 (FAS) - (06/04)
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