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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701055
Report Date: 12/28/2022
Date Signed: 12/28/2022 03:50:54 PM


Document Has Been Signed on 12/28/2022 03:50 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: 21DATE:
12/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:36 AM
MET WITH:Manisha Punni TIME COMPLETED:
12:55 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 Manisha Punni explained the purpose of the visit.

On 12/14/2022, R1 suffered a fall and was sent out to the ER. R1's primary care physician was notified. R1 also is being treated by Home Health for a stage two injury to the left heel. R1's does not have a pre-placement assessment or a current needs and service plan.

The facility also reported another fall for R2 on 12/11/22 and again on 12/24/22 in both cases R2 was sent out to the ER. R2's needs and service plan was completed on 2/28/22. The facility did not update the service plan to address the change in condition for falls.

The following deficiencies are being cited per Tittle 22 Regulations.

An exit interview was conducted with Resident Care Coordinator Manisha Punni and a copy of this report along with appeal rights was left at the facility.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 12/28/2022 03:50 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: 12/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
01/13/2023
Section Cited
CCR
80092.2(a)

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80092.2(a) If the licensee of an ARF or RCFE chooses to care for a client with a restricted health condition, as specified in Section 80092, the licensee shall develop and maintain, as part of the Needs and Services Plan, a written Restricted Health Condition Care Plan.
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Administrator shall submit an updated health care plan for R1. This shall be done by POC date 1/13/2023. Fax the information to CCL 916 263-4744
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This requirement is not met as evidenced by:
Based on records review, the licensee failed to maintain a recent copy of R1's restricted health care plan. This poses a potential health and safety risk to residents in care.
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Deficiency Dismissed
Type B
01/13/2023
Section Cited
CCR87463(c)

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The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any,
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The facility shall obtain a current Needs and Services Plan for R1 and R2.
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when there is significant change in the resident’s condition, or once every 12 months, LPA observed Needs and Services Plan is missing for R1 and not updated for R2.
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Written certification stating administrator has read regulation 87463 along with copies of current Needs and Services Plan to be sent to CCLD by POC date
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: 12/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2