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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366424198
Report Date: 11/06/2024
Date Signed: 11/06/2024 12:38:48 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
10/29/2024 and conducted by Evaluator Magda Malcore
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241029141012
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: 0DATE:
11/06/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Amanda RobertsTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Licensee is not ensuring the facility is in good repair
Licensee is not ensuring the facility is free from rodents and insects
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Magda Malcore and Renese Howell-Small conducted an unannounced visit to the facility to conduct a complaint investigation.
LPAs met with Amanda Roberts, facility representative, and discussed the purpose of the visit and was granted entry into the facility. The investigation consisted of LPAs observations and staff interviews.

Regarding the allegation, Licensee is not ensuring the facility is in good repair, LPAs observed in the facility laundry room, torn flooring, and a large open hole in the wall. LPAs observed in the facility’s bathrooms, bathroom toilets were rusted and were missing seats, and showers tiles were stained. LPAs observed in facility kitchen, kitchen floor was stained, kitchen cabinets doors were missing and a soiled and damaged wood panel underneath the kitchen sink. LPAs observed in the dining area near the kitchen, an open gap in the ceiling next to the light fixture.

Regarding the allegation, Licensee is not ensuring the facility is free from rodents and insects, LPAs observed dead ants and roaches in resident’s bedrooms, bathrooms, and kitchen area. Administrator Chris Tanabe stated that an exterminator did spray the facility; however, it was several months ago and will schedule an exterminator to treat and inspect the facility. LPAs did not observe rodents in the facility.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 56-AS-20241029141012
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: 11/06/2024
NARRATIVE
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Based on observations and interviews, the allegations are Substantiated. A substantiated finding means that the allegation(s) are valid because the preponderance of the evidence standard has been met.

An exit interview was conducted where reports (LIC9099, LIC9099-C &LIC9099-D) were discussed and provided with appeal rights to Facility Representative Roberts 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: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20241029141012
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: 11/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/29/2024
Section Cited
CCR
87303(a)(1)
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87303 Maintenance and Operation(a)The facility shall be clean, safe, sanitary and in good repair at all times...(1)Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary..condition.This requirement is not met at evidenced by:
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The Licensee/Administrator shall have repairs completed and facility cleaned by plan of correction date.
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The Licensee did not comply with the section cited above by not maintaining laundry area, facility ceiling, resident bathrooms, and kitchen area in good repair which poses a potential health and safety risk.
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Type B
11/29/2024
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times.Maintenance shall include provision of maintenance services and procedures...This requirement is not met at evidenced by:
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The Administrator stated that they will have an exterminator treat the facility. The Licensee/Administrator shall submit documentation of treatment to the licensing agency by plan of correction date.
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The Licensee did not comply with the section cited above by facility not being treated for several months for insects and rodents. LPAs observed dead ants and roaches in the facility, which poses a potentional health and safety risk.
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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: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3