<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
502701055
Report Date:
01/18/2024
Date Signed:
01/18/2024 02:47:29 PM
Document Has Been Signed on
01/18/2024 02:47 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
SACRAMENTO SOUTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
ASPEN VILLE CO
FACILITY NUMBER:
502701055
ADMINISTRATOR:
BHATIA, JASRAJ
FACILITY TYPE:
740
ADDRESS:
5412 KIERNAN AVENUE
TELEPHONE:
(209) 566-8080
CITY:
SALIDA
STATE:
CA
ZIP CODE:
95368
CAPACITY:
32
CENSUS:
31
DATE:
01/18/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
02:15 PM
MET WITH:
Executive Director Kash Kaur
TIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conducted Case Management Incident visit and met with administrator Executive Director Kash Kaur and explained the reason for the visit.
On 1/16/2024 Community Care Licensing received an Unusual Incident/Injury Report (LIC624) that Resident (R1) had an incident where R1 hit staff. Staff was able to redirect R1 and notified family & doctor. Staff & Residents in care where not harmed during the incident. The facility is monitoring R1 with half hour checks.
Exit interview conducted with administrator and copy of report left at facility
SUPERVISOR'S NAME:
Lisa Rios
TELEPHONE:
(916) 969-9685
LICENSING EVALUATOR NAME:
Jason Lund
TELEPHONE:
(916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE:
01/18/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/18/2024
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
1