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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366424198
Report Date: 07/29/2022
Date Signed: 07/29/2022 02:14:32 PM


Document Has Been Signed on 07/29/2022 02:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



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: 16DATE:
07/29/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:46 AM
MET WITH:Christopher TanabeTIME COMPLETED:
02:24 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced case management visit to follow up on an incident reports sent to licensing dated on 6/25/22, 7/22/22, and 7/23/22. The incidents involve six (6) residents that were missing narcotic medications. LPA met with Administrator Christopher Tanabe and explained the reason for the visit.

LPA Gardner reviewed medications, medication logs, and conducted interviews with staff. LPA Gardner found that the Administrator has interviewed staff members who were on shift when the medication went missing. The Administrator had each staff member write down a written statement of what happened on the days in question. The Administrator informed state licensing of each incident and filed police reports for each incident. There are cameras that are in the process of being installed in the facility. The facility is going to ensure there is only one set of keys for the medication cabinet per shift. The facility is going to create a sign in/sign out sheet for the medication cabinet keys. As of today, 7/29/2022, the Administrator is unsure of where the narcotic medication is at and/or who took the narcotic medication.

The facility will be receiving a citation for not supervising the staff and not establishing polices to ensure the residents medications do not go missing. The facility will also be receiving a citation for not providing medication safety and policy training to ensure staff has the knowledge and skill required to provide resident care.

Additionally, during today’s visit, LPA Gardner found unlocked medication in the kitchen on top of the microwave, in an unlocked kitchen cabinet, and on top of the medication cabinet. This facility will be issued a citation for not locking the medication.

Based on the observations made during today’s visit, three (3) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: AASPEN VILLAGE CARE III
FACILITY NUMBER: 366424198
VISIT DATE: 07/29/2022
NARRATIVE
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An exit interview was conducted, and this report LIC809, LIC 809D, and appeal rights were discussed and provided to Administrator Christopher Tanabe.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/29/2022 02:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: AASPEN VILLAGE CARE III
FACILITY NUMBER: 366424198

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/30/2022
Section Cited

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87205. Accountability of Licensee Governing Body. (a)The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves.
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This requirement was not met based on interviews and documentation review. The licensee did not comply with the section cited above by not supervising the staff and not having polices in place to ensure the residents medications do not go missing.
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Type A
07/30/2022
Section Cited

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87465. Incidental Medical and Dental Care. (h)The following requirements shall apply to medications which are centrally stored:(2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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This requirement was not met based on observation. The licensee did not comply with the section cited above by having unlocked medication in the kitchen on top of the microwave, in an unlocked kitchen cabinet, and on top of the medication cabinet.
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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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 07/29/2022 02:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: AASPEN VILLAGE CARE III
FACILITY NUMBER: 366424198

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2022
Section Cited

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87411.Personnel Requirements - General.In facilities licensed for sixteen (16) or more, the requirements of Section 87411(d) shall be met with planned on the job training program that utilizes orientation, skill training and continuing education.
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This requirement was not met based on interview with Administrator admitting the staff had not been trained on medication safety and policies. The licensee did not comply with the section cited above by not training the staff on medication safety and polices to ensure staff has the knowledge and skill required to provide resident care.
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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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4