366424198-7-2-2021-18-AS-JESL-CG8ULE-20220711154037

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366424198
Report Date: 07/02/2021
Date Signed: 07/02/2021 02:29:41 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
02/23/2021 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210223104657

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:	01:10 PM
MET WITH:	Administrator Christopher Tanabe		TIME COMPLETED:	01:43 PM

ALLEGATION(S):

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Facility failed to provide a refund upon resident’s death.

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 listed above. LPA George identified herself and discussed the purpose of the visit and the elements of the allegation(s) with Administrator Christopher. The investigation consisted of a review of pertinent documentation and interviews.

LPA conducted an interview with Administrator Christopher whom stated that once the initial request for the refund was made he was unsure if the resident was entitled to a refund and had been in the process of getting everything sorted out as he was looking for documentation to confirm the amount of rent that resident was supposed to pay, as well as R1s date of discharge. Chris stated that to help get some answers he had requested the last 6 months of cancelled

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)

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Control Number 18-AS-20210223104657

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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checks from R1s responsible party. Chris stated that after consulting with the licensee whom agreed with just giving the refund in the amount of $3,120, without having the documentation requested. The amount of the refund was calculated on when R1’s belongings being moved out on 6/8/20, and the refund days would be 6/9/20- 6/30/20. Based on observation, interview and record review the allegation of Facility failed to provide a refund upon resident’s death 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 a potential health, safety or personal rights 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-20210223104657

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 B 07/16/2021 Section Cited CCR 87507(5)(A)	1 2 3 4 5 6 7	87507 Admission Agreements (5) Refund conditions. (A) Facility policy concerning refunds, including the conditions under which a refund for advanced monthly fees will be returned in the event of a resident’s death, pursuant to Health and Safety Code section 1569.652. 1.Written notice, required pursuant to Health and Safety Code section 1569.652(d), must be made to the individual or entity contractually responsible for the payment of the resident’s fees, if that individual or entity is not also the resident’s responsible person or other individual or individuals as identified in the admission agreement. This requirement is not met as evidenced by: Based on observation, interviews and record review, the licensee did not ensure that a refund was issued on 1 out of 1 time after resident passed away. Which poses a potential health, safety, or personal rights risk to person's in care.	1 2 3 4 5 6 7	The licensee agrees to refund R1 responsible party for the amount of rent paid for the days indicated in June. The licensee will submit proof 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
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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)

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