366424198-7-2-2021-18-AS-JESL-CG8VBU-20220711161807

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366424198
Report Date: 07/02/2021
Date Signed: 07/02/2021 02:34:19 PM

Substantiated

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
01/06/2021 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210106144457

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: 15	DATE:	07/02/2021
		UNANNOUNCED	TIME BEGAN:	01:43 PM
MET WITH:	Administrator Christopher Tanabe		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff are not properly storing perishable foods.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegation(s) listed above. LPA George identified herself and discussed the purpose of the visit and the elements of the allegation(s) with Administrator Christopher Tanabe. The investigation consisted of a review of pertinent documentation and interviews.

LPA conducted an interview with Administrator whom stated that he is the primary one that does the grocery shopping for the facility, as they are no longer utilizing food companies to ship and deliver the facility’s food supply. Chris stated that there is ample food for each week and that the menu is followed but there are modifications on occasion. Chris denied that the facility runs out of food, in the event of an emergency, grocery food orders can be placed online for pickup and delivery and that $1400 is being spent each week on groceries.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021

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 3

Control Number 18-AS-20210106144457

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: 07/02/2021

NARRATIVE

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Chris revealed that the shopping is normally done on Monday’s, and he does complete the shopping out of town, which is about an hour and a half away from the facility. Additionally, Chris revealed that whatever he has purchased is not being transported in an ice chest, or in a manner that would keep the perishable food items cold. Based on interview and observation the allegation of Staff are not properly storing perishable foods is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. This posed an immediate health and safety risk to persons in care.

An exit interview was conducted, and a copy of this report, and appeal rights was provided to Administrator Christopher Tanabe.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20210106144457

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: 07/02/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/03/2021 Section Cited CCR 87599(b)(9)	1 2 3 4 5 6 7	87555 General Food Service Requirements (b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. Based on observation, interview and record review this requirement is not met as evidenced by: 1 out of 1 times the facility staff did not protect the safety acceptability, and nutritive values of the food. This poses an immediate health and safety risk to persons in care.	1 2 3 4 5 6 7	The licensee agrees to complete the shopping in town and will submit a receipt to the department by 5pm on the due date indicated.
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	1 2 3 4 5 6 7		1 2 3 4 5 6 7
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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: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3