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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701055
Report Date: 06/26/2023
Date Signed: 06/26/2023 03:12:43 PM


Document Has Been Signed on 06/26/2023 03:12 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, 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: 29DATE:
06/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Jasraj Bhatia - AdministratorTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ruth Wallace conducted Case Management Incident visit and met with administrator. he case management visit pertains to a missing controlled medication of Resident (R1).

LPA Wallace was at facility completing the Required 1 Year Annual Inspection visit when administrator mentioned missing medication of R1 which occurred on 6/24/23. LPA Wallace reviewed Medication Administration Record (MARS) of R1, Centrally Stored Medication Log, medication bubble pack, and medication procedures for medication technicians. LPA Wallace interviewed administrator who described the Centrally Stored Medication Log process, two medication technicians (MT's) counting medications during shift changes, and medication procedures.

The following documents were completed for Community Care Licensing (CCL), Stanislaus Sheriff's Department, and Local Ombudsman: SOC 341 Abuse Report, Incident Report, and Police Report.

After record reviews and interview, it was determined that even though the facility safeguarded the medications in a locked cabinet and has two MT's for counting medications during shift changes, the controlled medication still went missing. R1 did not miss any medication being given for am or PM shifts.

The following deficiency was observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22 and Health and Safety Code. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted with administrator. Copies of reports and appeal rights were provided.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2023
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 06/26/2023 03:12 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: ASPEN VILLE CO
FACILITY NUMBER: 502701055

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2023
Section Cited
HSC
1569.152(a)

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Health and Safety Code - 1569.152(a)
Safeguard of resident property; reimbursement for failure to make reasonable efforts; presumption; penalty
A residential care facility for the elderly, as defined in Section 1569.2, which fails to make reasonable efforts to safeguard resident property shall reimburse a resident for or replace stolen or lost resident property at its then current value. The facility shall be presumed to have made reasonable efforts to safeguard resident property if the facility has shown clear and convincing evidence of its efforts to meet each of the requirements specified in Section 1569.153. The presumption shall be a rebuttable presumption, and the resident or the resident's representative may pursue this matter in any court of competent jurisdiction.
The following requirement has not been met as evidenced by:
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Licensee submitted Medication Administration Record of R1, Centrally Stored Medication Log, medication bubble pack, incident report, SOC 341 Abuse Report, and medication procedures for medication technicians to LPA on 6/26/2023. Plan of Correction cleared on 6/23/23.
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LPA observed controlled medication pack missing from resident (R1) which poses a potential threat 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: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2023
LIC809 (FAS) - (06/04)
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