366424198-8-18-2023-56-AS-KCLS-CV6UK6-20230829153836

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366424198
Report Date: 08/18/2023
Date Signed: 08/18/2023 10:27:59 AM

Unsubstantiated

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
02/27/2023 and conducted by Evaluator Magda Malcore

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230227155936

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: 13	DATE:	08/18/2023
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Amanda Roberts, House Manager		TIME COMPLETED:	10:50 AM

ALLEGATION(S):

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Staff did not provide resident with a breathing treatment
Staff are not providing resident's authorized representatives with information regarding resident
Staff is being belligerent in the presence of resident
Staff are not meeting residents needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to the facility to continue the complaint investigation. LPA met with Amanda Roberts, House Manager and discussed the purpose of the visit.

Regarding the allegation staff did not provide resident with a breathing treatment, there is not enough evidence to corroborate this allegation.

Regarding the allegation, staff are not providing resident's authorized representatives with information regarding resident, Administrator and staff interviewed deny not providing resident’s authorized representatives with information regarding resident. Residents interviewed deny that staff have not provided their authorized representatives with information about them.

Unsubstantiated

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: 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.

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20230227155936

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: 08/18/2023

NARRATIVE

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Regarding the allegation, staff is being belligerent in the presence of resident, Administrator and staff interviewed deny being belligerent in the presence of any residents. Residents interviewed deny that staff have been belligerent in their presence.

Regarding the allegation that staff are not meeting resident’s needs, Administrator and staff deny not providing residents with their daily needs and services. Residents interviewed deny that staff are not meeting their care needs, in addition all residents interviewed stated that they feel safe and comfortable at the facility.

Based on observations, interviews and document review, there is not enough evidence to corroborate the allegations, therefore, the allegations are Unsubstantiated. Unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where this report was discussed and a copy with appeal rights was provided to the House Manager 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: 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

LIC9099 (FAS) - (06/04)

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