366424198-7-2-2021-18-AS-JESL-CG8VC7-20220711161841

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366424198
Report Date: 07/02/2021
Date Signed: 07/02/2021 02:45:18 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
11/16/2020 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20201116103846

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:	02:00 PM
MET WITH:	Administrator Christopher Tanabe		TIME COMPLETED:	02:44 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff stole resident's personal lock box.

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.

LPA George conducted an interview with the Administrator Christopher Tanabe.
After multiple requests the facility staff was not able to produce Resident 1 (R1s) lock box and its contents (7 rings, $1200 and personal notes) estimated to be worth $1700. The administrator Christopher Tanabe stated that he was not working at the facility when Resident #1(R1) was placed there, however he was able to confirm with the previous administrator Crystal

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-20201116103846

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

Green that there was in fact a lock box, that was with the rest of resident’s personal property. Chris stated he looked all over for it and cannot locate the box anywhere. In addition a police report was filed by facility staff Mary Guest, with San Bernardino County Sheriff's department, report # 232002713, regarding the incident. Based on interviews the allegation of Facility staff stole resident's personal lock box 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 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-20201116103846

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 87217(j)	1 2 3 4 5 6 7	87217 Safeguards for Resident Cash, Personal Property, and Valuables (j) Upon the death of a resident, all cash resources, personal property, and valuables of that resident shall immediately be safeguarded. Based on observation, interview and record review this requirement is not met as evidenced by: 1 out of 1 times the facility did not safeguard R1’s personal property. This poses a potential health and safety risk to persons in care.	1 2 3 4 5 6 7	The licensee agrees to refund the estimated amount of $1700 to R1s responsible party for the contents of the lock box. The licensee will submit proof to the department by 5pm on the due date indicated.
	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
	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)

Page: 3 of 3