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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366424198
Report Date: 01/12/2023
Date Signed: 01/12/2023 02:09:14 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
01/09/2023 and conducted by Evaluator Ryan Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230109110614
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: 12DATE:
01/12/2023
UNANNOUNCEDTIME BEGAN:
09:34 AM
MET WITH:Amanda Tucker- Facility ManagerTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Staff interferes with resident visiting.
Staff will not give resident's conservators requested medical/facility documents.
Staff do not maintain facility in good repair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ryan Gardner arrived at the facility unannounced to initiate and deliver findings for the above complaint allegations. LPA met with Facility Manager Amanda Tucker and explained the reason for the visit.

During today’s visit, LPA toured the facility, conducted interviews with residents and staff, reviewed and was provided facility documents.

For allegation, Staff interferes with resident visiting:

Upon arrival to the facility, LPA observed two (2) handwritten postings, one (1) on the front entry door and one (1) above the visitor sign in/sign out area that stated, “No visitors during mealtimes: Lunch 11:30 am to 12:30 pm Dinner: 4:30pm to 5:30pm.” During interviews conducted, LPA was informed that staff put the new visitor rule in place around the beginning of January 2023.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
01/09/2023 and conducted by Evaluator Ryan Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230109110614

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: 12DATE:
01/12/2023
UNANNOUNCEDTIME BEGAN:
09:34 AM
MET WITH:Amanda Tucker- Facility ManagerTIME COMPLETED:
02:20 PM
ALLEGATION(S):
1
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3
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5
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8
9
Staff do not keep resident's breathing treatment supplies sanitary.
Staff do not provide resident with clean linen.
Staff do not change resident's diaper in a timely manner.
Staff do not allow families to be bring residents food.


INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ryan Gardner arrived at the facility unannounced to initiate and deliver findings for the above complaint allegations. LPA met with Facility Manager Amanda Tucker and explained the reason for the visit.

During today’s visit, LPA toured the facility, conducted interviews with residents and staff, reviewed and was provided facility documents.

For allegation, Staff do not keep resident's breathing treatment supplies sanitary:

During facility tour, LPA observed Resident R1 being provided a sanitary mask for the breathing treatment. LPA observed staff clean the mask before and after the breathing treatment. During interviews conducted, LPA found that the mask for the breathing treatment is cleaned before and after use.


Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
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 6
Control Number 56-AS-20230109110614
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: AASPEN VILLAGE CARE III
FACILITY NUMBER: 366424198
VISIT DATE: 01/12/2023
NARRATIVE
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For allegation, Staff do not provide resident with clean linen:

During facility tour, LPA observed the residents to have visible clean linens. During interviews conducted, LPA found that the facility washes the resident’s linens two (2) to three (3) times a week. The residents’ linens will be washed more often by staff if needed.

For allegation, Staff do not change resident's diaper in a timely manner:

During interviews conducted, LPA found that residents diapers are changed every two (2) hours. The resident’s diapers will be changed more often as needed.

For allegation, Staff do not allow families to be bring residents food:

During interviews conducted, LPA found that residents families are allowed to bring food to the facility. The facility just requests that visitors and families only provide food to the resident they are visiting due to residents having different dietary needs.

Based on the evidence gathered during today’s investigation, the four (4) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC9099) was discussed and provided to Facility Manager Amanda, along with a copy of the appeal rights.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 56-AS-20230109110614
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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: 01/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/14/2023
Section Cited
CCR
87468.1(a)(11)
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87468.1 Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.
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The licensee has agreed to read regulation 87468.1 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to train staff of the approved admissions agreement visiting hours. The licensee has agreed to remove the handwritten postings stating visitors are not allowed during mealtimes.
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Based on observation, interview and record review, the licensee did not comply with the section cited above evidenced by adding a facility rule that’s not in the admissions agreement that prevents residents from having visitors during mealtimes which poses a potential health, safety or personal rights risk to persons in care.
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 The POC is due by 1/14/2023.
Type B
01/14/2023
Section Cited
CCR
87506(c)(1)
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87506 Resident Records. (c) All information and records obtained from or regarding residents shall be confidential. (1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents. The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative.
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The licensee has agreed to read regulation 87506 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to train staff on resident records and has agreed to provide LPA proof that the legal conservator was given the documents requested.
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Based on interview and record review, the licensee did not comply with the section cited above evidenced by denying resident records to a resident’s legal conservator who is appointed for estate and person which poses a potential health, safety or personal rights risk to persons in care.
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 The POC is due by 1/14/2023.
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: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 56-AS-20230109110614
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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: 01/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/26/2023
Section Cited
CCR
87303(a)
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87303. Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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The licensee has agreed to read regulation 87303 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to repair the call button and send LPA a photo once it is repaired. The POC is due by 1/26/2023.
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Based on observation and interview, the licensee did not comply with the section cited above evidenced by having exposed wires from a broken call button behind the bed in bedroom number eight (8) which poses a potential health, safety or personal rights risk to persons in 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: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 56-AS-20230109110614
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: AASPEN VILLAGE CARE III
FACILITY NUMBER: 366424198
VISIT DATE: 01/12/2023
NARRATIVE
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During document review, LPA found that the admissions agreement for the facility states that visitors are allowed from 8:00 am to 7:00pm. The facility not allowing visitors during a reasonable time frame poses a potential health, safety, or personal rights risk to persons in care.

For allegation, Staff will not give resident's conservators requested medical/facility documents:

During interviews conducted, LPA was informed that the facility thought that Resident R1’s conservator only oversees R1’s estate. During document review, LPA found that R1’s conservator oversees both estate and person for R1. LPA found that R1’s conservator has access to R1’s medical documents and facility documents. The facility denying requested documents to R1’s conservator poses a potential health, safety, or personal rights risk to persons in care.

For allegation, Staff do not maintain facility in good repair:

During facility tour, LPA found that there were exposed wires from a broken call button behind the bed in bedroom number eight (8) which poses a potential health, safety or personal rights risk to persons in care.

Based on the evidence gathered during today’s investigation, the three (3) allegations listed above are deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegations are valid because the preponderance of evidence the standard has been met.

During today’s visit, three (3) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC9099) and LIC9099D was discussed and provided to Facility Manager Amanda, along with a copy of the appeal rights.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6