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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366424198
Report Date: 09/29/2021
Date Signed: 09/29/2021 04:05:54 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/24/2021 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210924133704
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: 15DATE:
09/29/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Crystal GreenTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Staff speak inappropriately to resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to commence a complaint investigation. LPA Brown identified herself and discussed the purpose of the visit and the elements of the allegation(s) with House Manager Crystal Green.

The investigation was conducted by LPA Melody Brown. The investigation consisted of interviews with relevant parties. The first allegation indicates that staff speak inappropriately to resident in care. LPA Brown interviewed Administrator Christopher Tanabe (S1) regarding this allegation and the events in which the allegation is based upon. Administrator Tanabe confirmed that S5 speaks inappropriately to residents. Administrator Tanabe also added that their investigation indicated that Staff 5 (S5) was very rude, bossy and doesn’t want to do anything at the facility. Administrator Tanabe also reported that S5 was terminated as a result of their investigations.



Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
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 4
Control Number 18-AS-20210924133704
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 09/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2021
Section Cited
CCR
87468.1
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Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met by
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Licensee agrees movng forward to monitor their relationship with rsidents and to hold themselves to a professional matter at all times. No further plan of correction needed.
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Based on interviews, the Licensee did not provide at least one resident (R1) with dignity in thier relationships with staff (S5) as observed by Licensee as being rude, bossy and speaking inappropriately to R1. This poses a potential personal rights violation to R1.
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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: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/24/2021 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210924133704

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: 15DATE:
09/29/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Crystal GreenTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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9
Staff handle resident in a rough manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to commence a complaint investigation. LPA Brown identified herself and discussed the purpose of the visit and the elements of the allegation(s) with House Manager Crystal Green.

The investigation was conducted by LPA Melody Brown. The investigation consisted of interviews with relevant parties. The second allegation indicates that staff handle resident in a rough manner. During the investigation, LPA Brown did not find evidence to corroborate the allegation based on interview with staffs and residents.

Based on the evidence, the allegation that staff handle Resident 1 (R1) in a rough manner is UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means 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, therefore the allegation is unsubstantiated at this time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20210924133704
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: AASPEN VILLAGE CARE III
FACILITY NUMBER: 366424198
VISIT DATE: 09/29/2021
NARRATIVE
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Based on interviews conducted with staffs and residents , the above allegation is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4