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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701055
Report Date: 08/04/2021
Date Signed: 08/04/2021 02:36:54 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ASPEN VILLE COFACILITY NUMBER:
502701055
ADMINISTRATOR:BHATIA, JASRAJFACILITY TYPE:
740
ADDRESS:5412 KIERNAN AVENUETELEPHONE:
(669) 265-4603
CITY:SALIDASTATE: CAZIP CODE:
95368
CAPACITY:32CENSUS: 5DATE:
08/04/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:JASRAJ BHATIATIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Sarah Hurt conducted an announced visit for the purpose of conducting a Pre-Licensing evaluation. LPA met with Applicant/Administrator (AD) Jasraj Bhatia. The initial application to operate an RCFE Residential Care Facility for Elderly was submitted to the Central Applications Bureau (CAB) on June 21, 2021.

LPA Hurt observed the following:

Structure:
Facility is a single story building with 16 client bedrooms and 10 bathrooms, and 3 central showers. The facility has a med room, activity room, linen room, stock room, and supply room. Facility has common areas, dining area, outdoor area and kitchen. The staff break room is located in the back of the facility.

Signal System:
Is not required for this facility.
Bedrooms Residents:
All bedrooms will accommodate resident furnishings for 5 clients
Bathrooms:
All bathrooms have a working toilet, wash basin, and shower.
Linens and Hygiene Supplies:
Adequate supply of linens is stored in the garage.
Emergency Phone Numbers, Exit Plan, and Sample Menu:
All were posted and readily available for review in common areas.
Food Service:
Adequate supply of 7-day non-perishable and 2 day perishables stored in the kitchen.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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