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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502701055
Report Date: 06/27/2022
Date Signed: 06/28/2022 01:07:05 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/19/2022 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 27-AS-20220519092008
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: 15DATE:
06/27/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Licensee Jasrajh Bhatia TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff yell at residents while in care.
Staff hit resident with a hoyer lift.
Resident's showering needs are not being met.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit on June 27,2022 at 10: 30 a.m. to investigate a complaint on the allegations listed above. LPA met with Licensee Jasraj Bhatia and explained the purpose of today's visit.

Regarding the allegation Staff yell at residents while in care. Based on LPA interviews with staff and residents the staff does appear to yell at facility residents. LPA interviewed 4 facility residents and 2 staff members. Three of the four facility residents interviewed stated they have heard a specific female staff member speak harsh, aggressive, and even yell at the residents. The residents all stated they did not want to give her name or could not pronounce it. Therefore, this allegation is SUBSTANTIATED.


Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/19/2022 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 27-AS-20220519092008

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: 15DATE:
06/27/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Licensee Jasrajh Bhatia TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff does not properly store food.
Staff mismanages resident's medication.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit on June 27,2022 at 10:30 a.m. to open a complaint on the allegations listed above. LPA met with Licensee Jasraj Bhatia and explained the purpose of today's visit.

Regarding the allegations Staff does not properly store food. Based on LPA observation the kitchen staff is properly storing food. LPA toured the facility kitchen area is clean. LPA observed the kitchen staff cleaning the kitchen and wiping down the counters. LPA observed the food inside the fridge to be clean, and the food is properly stored. Therefore, the allegation is deemed UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022
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 27-AS-20220519092008
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CO
FACILITY NUMBER: 502701055
VISIT DATE: 06/27/2022
NARRATIVE
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Continued from 9099..


Regarding the allegation staff mismanages resident's medication. Based on LPA interviews and records reviewed the staff is properly managing residents’ medications. LPA reviewed the facility MAR for Resident 1 and it documents her medications being given timely and correctly. LPA spoke with Resident 1 and she stated she is being given her medications timely and correctly. Resident 2 stated she was aware of an incident with the medications in her room inside an Easter egg, but she has no idea how they got there. LPA interviewed 3 facility staff members, and none have any knowledge of how the Easter egg with medications ended up in Resident 1’s bedroom. Therefore, the allegation is deemed UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies cited per Title 22 Regulations.

Exit interview conducted with Licensee Jasrajh Bhatia and a copy of this report left at the facility.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20220519092008
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CO
FACILITY NUMBER: 502701055
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
07/14/2022
Section Cited
CCR
87468.1(a)(1)
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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:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. The following requirement has not been met as evidenced by:
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Licensee will send proof of personal rights training of facility staff to LPA by POC date 06/28/2022.
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Based on resident interviews staff does yell and speak rudley to residents at times which poses an immediate health, safety, or personal rights risk to residents in care.
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Deficiency Dismissed
Type B
07/13/2022
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements – General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. [...]
The following requirement has not been met as evidenced by:
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Licensee will conduct training for all staff on resident showering needs to LPA by POC date of 07/13/2022.
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Based on resident interviews and records reviewed the residents are not being assisted with their showering needs which poses a potentiol health, safety, or personal rights risk to residents 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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20220519092008
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CO
FACILITY NUMBER: 502701055
VISIT DATE: 06/27/2022
NARRATIVE
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Continued from 9099..

Regarding the allegation Staff hit resident with a hoyer lift. Based on LPA interviews the staff did hit a resident with a hoyer lift. Resident 1 stated she was hit with the hoyer lift one out of the three times she was lifted. Resident 1 stated it was more than likely her own fault she can be a little fidgety and she does not think staff did it on purpose. Therefore, this allegation is SUBSTANTIATED.

Regarding the allegation Resident's showering needs are not being met. Based on records reviewed and resident interviews the residents showering needs are not being met. LPA interviewed three facility residents that needed showering assistance, and two of the residents stated they are not being assisted with showering needs twice every week as they should be. The facility records show facility staff is not properly documenting residents showers. Therefore, this complaint is SUBSTANTIATED.

The following deficiencies are being cited today Per Title 22 Regulations. Exit interview conducted with Licensee Jarajh Bhatia and a copy of this report along with appeals rights provided.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20220519092008
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CO
FACILITY NUMBER: 502701055
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
07/07/2022
Section Cited
CCR
87606(a)
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87606 Care of Bedridden Residents (a) Unless otherwise specified, this section applies to licensees who accept or retain residents who are bedridden. The licensee shall be permitted to accept and retain residents who are or shall become bedridden, if all the following conditions are met. The following requirement has not been met as evidenced by:
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Licensee will send proof of relocation of resident 1 to LPA by POC date 07/07/2022.
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Based on records reviewed and LPA interviews resident 1 is bedridden which poses a potential risk to the health, safety, or personal rights of residents 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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6