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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
366424198
Report Date:
10/27/2023
Date Signed:
10/27/2023 05:17:16 PM
Document Has Been Signed on
10/27/2023 05:17 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
,
1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE
,
CA
92507
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:
12
DATE:
10/27/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
12:35 PM
MET WITH:
Marlene Rasmussen'niesen, Facility staff
TIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Amanda Roberts, House Manager and Marlene Rasmussen'niesen, facility staff and discussed the purpose of the visit.
The facility is a Residential Care Facility for the Elderly (RCFE). License capacity of (23) with a current census of (12). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:
Physical Plant:
Indoor passageways are free of obstruction. The facility has sufficient lighting and is maintained at a comfortable temperature. The hot water temperature in residents' bathrooms measured 108 degrees F. Resident’s bedrooms have sufficient lighting and furniture in good repair. Facility has operating carbon monoxide alarms and telephone service. The facility has sufficient linen, towels, and personal hygiene items for residents. The facility has posted in a common area, Ombudsman poster and facility license. LPA observed disinfectants and cleaning solutions were stored in an unlocked cabinet underneath the kitchen sink and in a unlocked cabinet in the laundry room. LPA observed oxygen tanks without posted "No Smoking-Oxygen in Use” signs in the areas of oxygen use. The facility was not maintained free of incontinence odors.
Yards/Outside:
Outdoor passageways are free of obstruction. The facility has no bodies of water accessible to residents in care. The facility is enclosed with self-latching gates. Outdoor shaded area is sufficient for resident activities.
SUPERVISOR'S NAME:
Karen Clemons
TELEPHONE:
(951) 248-0349
LICENSING EVALUATOR NAME:
Magda Malcore
TELEPHONE:
951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE:
10/27/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/27/2023
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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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
VISIT DATE:
10/27/2023
NARRATIVE
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32
Food Service:
Facility has sufficient non-perishable and perishable food supply for residents in care. The refrigerator and freezer are operating in a healthful manner.
Care & Supervision
: Facility has 24-hour care staff. Staff working at the facility have
criminal record clearances or exemptions through the Department.
Record Review:
(4) resident files reviewed were observed to be complete. (4) staff files were reviewed. LPA observed facility did not maintain documentation of staff #1's (S1's) Dementia training. Facility did not maintain documentation of staff #2's (S2's) health screening and examination results. Facility did not maintain proof of liability insurance on file. Facility did not maintain record of last emergency drill on file.
Facility did not maintain record of a emergency and disaster plan.
Medical Related Services
: All medication is centrally stored and kept in a locked in a cabinet.
Based on observations and record review, deficiencies were cited during today's visit and a plan of correction was discussed.
An exit interview was conducted where this report was discussed and a copy provided to facility staff 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:
10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/27/2023
LIC809
(FAS) - (06/04)
Page:
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Document Has Been Signed on
10/27/2023 05:17 PM
- 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:
10/27/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Storage Space
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Type A
Section Cited
CCR
87309(a)(1)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observations, the licensee did not comply with section cited by: disenfectants and cleaning solutions were kept in an unlocked cabinet underneath the kitchen sink and in a unlocked cabinet in the laundry room, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
10/28/2023
Plan of Correction
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2
3
4
Licensee/Administrator shall submit to the licensing agency proof that the toxins were removed from unlocked cabinets and kept in a locked location by POC date.
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:
10/27/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/27/2023
LIC809
(FAS) - (06/04)
Page:
3
of
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Document Has Been Signed on
10/27/2023 05:17 PM
- 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:
10/27/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA file review, the licensee did not comply with the section cited above by facility did not maintain documentation of staff #2's (S2's) health screening and examination results which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/15/2023
Plan of Correction
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2
3
4
Licensee/Administrator shall submit to the Licensing agency proof correction by POC date
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:
10/27/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/27/2023
LIC809
(FAS) - (06/04)
Page:
4
of
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Document Has Been Signed on
10/27/2023 05:17 PM
- 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:
10/27/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA file review, the licensee did not comply with the section cited above by facility did not maintain proof of liability insurance on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/15/2023
Plan of Correction
1
2
3
4
Licensee/Administrator shall submit to the Licensing agency proof of correction by POC date.
Section Cited
Personal Accommodations and Services
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
10/27/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/27/2023
LIC809
(FAS) - (06/04)
Page:
5
of
12
Document Has Been Signed on
10/27/2023 05:17 PM
- 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:
10/27/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(d)
Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA file review, the licensee did not comply with the section cited above: facility did not maintain documentation of staff #1's (S1's) Dementia training. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/15/2023
Plan of Correction
1
2
3
4
Section Cited
Personnel Records
Deficient Practice Statement
1
2
3
4
.
POC Due Date:
Plan of Correction
1
2
3
4
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:
10/27/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/27/2023
LIC809
(FAS) - (06/04)
Page:
6
of
12
Document Has Been Signed on
10/27/2023 05:17 PM
- 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:
10/27/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Type B
Section Cited
HSC
1569.69(e)(3)(C)
Other Provisions
(e) Each person who provides employee training under this section shall meet the following education and experience requirements: (3) The licensed residential care facility for the elderly shall maintain the following documentation on each person who provides employee training under this section: (C) The times, dates, and hours of training provided.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observations, the licensee did not comply with the section cited above: facility did not maintained dates and hours of employee training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/15/2023
Plan of Correction
1
2
3
4
Licensee/Administrator shall provide to the Licensing agency proof of correction by POC date
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:
10/27/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/27/2023
LIC809
(FAS) - (06/04)
Page:
7
of
12
Document Has Been Signed on
10/27/2023 05:17 PM
- 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:
10/27/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Type B
Section Cited
HSC
1569.695(a)(2)
Other Provisions
(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observations, the licensee did not comply with the section cited above by: Facility did not maintain record of a emergency and disaster plan, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/15/2023
Plan of Correction
1
2
3
4
Licensee/Administrator shall submit to the licensing agency proof of disaster plan by POC date.
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:
10/27/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/27/2023
LIC809
(FAS) - (06/04)
Page:
8
of
12
Document Has Been Signed on
10/27/2023 05:17 PM
- 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:
10/27/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on file review, the licensee did not comply with the section cited above by facility did not maintain record of last emergency drill, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/15/2023
Plan of Correction
1
2
3
4
Licensee/Administrator shall submit to the licensing agency proof of current emergency drill conducted at the facility by POC date.
Section Cited
Oxygen Administration - Gas and Liquid
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
10/27/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/27/2023
LIC809
(FAS) - (06/04)
Page:
9
of
12
Document Has Been Signed on
10/27/2023 05:17 PM
- 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:
10/27/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observations, the licensee did not comply with the section cited above by: facility did not have posted "No Smoking-Oxygen in Use” signs in areas were oxygen equipment is used, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/15/2023
Plan of Correction
1
2
3
4
Licensee/Administrator shall submit to the licensing agency proof of posted oxygen signage by POC date
Section Cited
Managed Incontinence
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
10/27/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/27/2023
LIC809
(FAS) - (06/04)
Page:
10
of
12
Document Has Been Signed on
10/27/2023 05:17 PM
- 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:
10/27/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87625(b)(3)
Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observations, the licensee did not comply with the section cited above: The facility was not free of incontinence odors, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/15/2023
Plan of Correction
1
2
3
4
Licensing/Administrator shall submit to the Licensing Agency proof of staff training on above cited regulation by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
10/27/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/27/2023
LIC809
(FAS) - (06/04)
Page:
11
of
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