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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701055
Report Date: 10/24/2022
Date Signed: 10/25/2022 08:22:58 AM


Document Has Been Signed on 10/25/2022 08:22 AM - 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, 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: 21DATE:
10/24/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Karen Langley (Staff)TIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson arrived at this facility unannounced to conduct a case management visit. LPA met with Karen Langley and explained the purpose of the visit.

On 10/14/2022, R1 suffered a superficial wound when a hook from R2's project was removed from R1's right buttocks area. The facility removed the hook and applied basic first aid. R1's primary care physician was not notified and R1 was not seen by any other medical professional.

The facility did not update R2's service plan to address the danger of having fish hooks in or around others that may be harmed as a result of these hooks being displaced.

LPA was told that the facility had a meeting with PACE to address the care plan and the safety risk that having the fish hooks on his desk has placed on residents in care. LPA was unable to review any documentation that addressed the safety concerns for supervising R1 while he is working with the fish hooks.

During the tour of the facility with Karen at approximately 12:00 PM, LPA Johnson and Staff observed in room 6B unlocked fish hooks in the cut out areas of the desk.(Photos taken) Also observed during the tour in the back patio area was a can of starter fluid. (Photo taken).

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, Deficiencies are being cited. An exit interview was conducted with the Karen and a copy of this report was provided.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2022
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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Document Has Been Signed on 10/25/2022 08:22 AM - 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: ASPEN VILLE CO
FACILITY NUMBER: 502701055

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/25/2022
Section Cited

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87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
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This requirement is not met as evidenced observation and photos LPA Johnson and Staff observed in room 6B unlocked fish hooks in the cut out areas of the desk.(Photos taken) Also observed during the tour in the back patio area was a can of starter fluid. (Photo taken). This poses an immediate safety risk to residents in care.
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Plan to be submitted to LPA by POC due date.

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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: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2022
LIC809 (FAS) - (06/04)
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