<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366424198
Report Date: 07/02/2021
Date Signed: 07/02/2021 05:45:30 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
08/18/2020 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200818144016
FACILITY NAME:AASPEN VILLAGE CARE IIIFACILITY NUMBER:
366424198
ADMINISTRATOR:MUSHTAQ KHANFACILITY TYPE:
740
ADDRESS:56524 ANTELOPE TRAILTELEPHONE:
(760) 228-2729
CITY:YUCCA VALLEYSTATE: CAZIP CODE:
92284
CAPACITY:23CENSUS: 15DATE:
07/02/2021
UNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Admiistrator Christopher TanabeTIME COMPLETED:
03:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Air conditioner is in disrepair.
Staff did not maintain a comfortable room temperature for resident.
Resident's room is in disrepair.

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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.

Allegation: Air conditioner is in disrepair
On 8/20/20 LPA conducted interviews with facility staff and residents. It was confirmed that the air conditioner was not working. At the time of the visit the thermostat read 80 Fahrenheit degrees in one residents’ bedroom, on one side of the facility. As to where LPA observed that the thermostat read a temperature of 62 degrees to compensate and assist with needing to cool down the other half of the facility, due to the air conditioner being broken. Per Administrator the electrician was coming out in the afternoon to replace all the filters and conduct an additional inspection. There were 2 additional AC window units installed, and 6 residents were relocated until the AC is restored and working properly.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (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 5
Control Number 18-AS-20200818144016
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The air conditioner had been broken for a couple of weeks per Administrator. Based on the information provided from Administrator’s Crystal Green and Tammy Barnett the allegation of Air conditioner is in disrepair is SUBSTANTIATED.

Allegation: Staff did not maintain a comfortable room temperature for resident
Based on observation and interview the allegation was corroborated. On 8/20/20 at 1:17pm At the time of the visit the thermostat read 80 Fahrenheit degrees in one residents’ (R1) bedroom, on one side of the facility. As to where LPA observed that the thermostat was set to a low temperature of 68 degrees to compensate and assist with needing to cool down the other half of the facility, due to the air conditioner being broken. Resident # 2 (R2) bedroom was found to be 70 degrees Fahrenheit. Therefore, the allegation of Staff did not maintain a comfortable room temperature for resident is SUBSTANTIATED.

Allegation: Resident's room is in disrepair
During the initial visit on 08/20/20, LPA conducted a virtual tour of the physical plant and did not observe any light fixtures, or detectors hanging by wires. Per the previous Administrator the detectors are a combination of smoke as well as carbon monoxide. There was no detector present in Resident # 1 (R1) room. Administrator stated that there was a smoke detector hanging on the ceiling, right outside of the bedroom of room #7. R1 was relocated due to the air conditioner being broken and had to be relocated to a different room, until the air conditioner is repaired. LPA conducted a follow up visit on 7/2/21. During the inspection of the physical plant, LPA observed that the detectors were not a combination and the facility, did not have any carbon monoxide detectors. Administrator Chris brought the detector box to LPA. LPA observed that the box, did not state that the detector was a combination of smoke and carbon monoxide. Based on observation and interviews the allegation of Resident's room is in disrepair 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.

An exit interview was conducted, and a copy of this report and appeal rights was provided to Administrator Christopher Tanabe.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (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: 4 of 5
Control Number 18-AS-20200818144016
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
07/02/2021
Section Cited
CCR
87303(a)(2)
1
2
3
4
5
6
7
87303 (a)(2) Maintenance and Operation
(b) A comfortable temperature for residents shall be maintained at all times. (2) The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature.

Based on observation, interview and record review this requirement is not met as evidenced by: 1 out of 1 times the facility was not at a comfortable temperature. This poses a potential health and safety risk to persons in care.
1
2
3
4
5
6
7
The licensee agrees to have the air conditioner repaired and submit the invoices to the department by 5pm on the due date indicated.

Type A
07/02/2021
Section Cited
HSC
1569.311
1
2
3
4
5
6
7
1569.311 Carbon monoxide detectors required; inspection
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.
1
2
3
4
5
6
7
The licensee will purchase and have the carbon monoxide detector installed at the facility. Proof will be submitted to the department, by 5pm on the due date indicated.
Type B
07/16/2021
Section Cited
CCR
87303(b)(2)
1
2
3
4
5
6
7
87303 (b)(1) Maintenance and Operation
(b) A comfortable temperature for residents shall be maintained at all times. (1) The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C).

Based on observation, interview and record review this requirement is not met as evidenced by: 1 out of 1 times the facility was not at a comfortable temperature. This poses a potential health and safety risk to persons in care.
1
2
3
4
5
6
7
The licensee agrees to have the air conditioner repaired and submit the invoices to the department by 5pm on the due date indicated.
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 EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (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: 5 of 5
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
08/18/2020 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200818144016

FACILITY NAME:AASPEN VILLAGE CARE IIIFACILITY NUMBER:
366424198
ADMINISTRATOR:MUSHTAQ KHANFACILITY TYPE:
740
ADDRESS:56524 ANTELOPE TRAILTELEPHONE:
(760) 228-2729
CITY:YUCCA VALLEYSTATE: CAZIP CODE:
92284
CAPACITY:23CENSUS: 15DATE:
07/02/2021
UNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Administrator Christopher TanabeTIME COMPLETED:
03:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not prevent resident from having an allergic reaction.
Staff did not provide a comfortable bed for resident.
Resident's room is in disrepair.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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.

Allegation: Staff did not prevent resident from having an allergic reaction
LPA reviewed pertinent documents such as R2s physician’s report which revealed that the only allergies that R2 has are to medications, and that there is no need for an Epipen. R2s physician report does not indicate that R2 is diagnosed with any type of skin condition. Administrator Tammy did confirm that R2 did complain of having itchy skin, however per Administrator Tammy R2’s skin was observed to be dry and without a rash. There was not a significant reaction to indicate that R2 had an allergic reaction to the soap (Nivea) that was used and had no need to be sent out for further medical treatment. The allegation of Staff did not prevent resident from having an allergic reaction is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (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: 2 of 5
Control Number 18-AS-20200818144016
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Staff did not provide a comfortable bed for resident

LPA conducted a tour and observed R2s temporary bed to have the required linen. The mattress was intact with no visible springs or indentations. Administrator Tammy stated that staff moved the mattress from R2’s room, however, did report that their back hurt, and this was an isolated incident as the complaint was to until R2 was moved to east wing of the building. LPA conducted interviews and there were not any complaints regarding the mattresses. The allegation of Staff did not provide a comfortable bed for resident is UNSUBSTANTIATED.

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (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: 3 of 5