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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366424198
Report Date: 11/21/2024
Date Signed: 11/21/2024 01:54:43 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/21/2024 01:54 PM - 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:AASPEN VILLAGE CARE IIIFACILITY NUMBER:
366424198
ADMINISTRATOR/
DIRECTOR:
MUSHTAQ KHANFACILITY TYPE:
740
ADDRESS:56524 ANTELOPE TRAILTELEPHONE:
(760) 369-9294
CITY:YUCCA VALLEYSTATE: CAZIP CODE:
92284
CAPACITY: 23TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
11/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Amanda Roberts/ Christopher TanabeTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Sarina Ramirez conducted an announced visit to the facility to conduct a required comprehensive annual inspection. LPA was greeted and granted entry by the House Manager Amanda Roberts,

The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (23) and current census of (0) residents. Last resident residing at facility was on April 4, 2024. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

The facility has no swimming pool or similar bodies of water. The facility has sufficient indoor and outdoor space for resident activities. Facility has twelve (12) bedrooms and seven (7) bathrooms. One (1) bedroom was equipped with a bed. The facility has a small food supply, overall the facility is empty and currently in a pending decision to either remodel or sell.

No deficiencies were cited during today's inspection.

An exit interview was conducted where this report was discussed and a copy provided to Administrator Christopher Tanabe at the conclusion of the visit.

Karen ClemonsTELEPHONE: (951) 836-2784
Sarina RamirezTELEPHONE: (951) 248-0307
DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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