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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701055
Report Date: 10/06/2023
Date Signed: 11/28/2023 04:15:34 PM


Document Has Been Signed on 11/28/2023 04:15 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/06/2023 05:29 PM

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

NARRATIVE
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"This report was amended to change the introductory language in the first paragraph."

Licensing Program Analyst (LPA) Albert Johnson arrived at facility to conduct a Case Management visit to address the appeal and the reissuing of the corrected citation which the facility was given on 12/28/22 for "Restricted Health Condition Care Plan" and "Reappraisals."

The facility has appealed the citations given on 12/28/2022. The appeal states that the Department's evaluator misquoted this regulation as written in the report. The regulation cited applies to an Adult residential Facility (ARF) and does not apply to a Residential Care Facility for the Elderly (RCFE). The appeal further stated that 2 days after R1’s fall on December 14, 2022 the facility updated the Needs and Services plan of January 4, 2022 and on December 16, 2022 and includes the care plan for R1’s heel wound which states home health would be monitoring and assisting. Both citations appealed for the visit on 12 /28/2022 were granted, and the citations dismissed. The Department will be issuing a correction to the citation given on 12/28/2022 to include the RCFE requirement for "restricted health conditions."

During the review of this matter the Department confirmed that the facility did not have doctors’ orders for R1's home health services to determine the stage of the pressure injury available on 12/28/2022,

Continued on the attached 809C page.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2023
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 3


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
VISIT DATE: 10/06/2023
NARRATIVE
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 However, the facility provided the Department with a Home Health Orders today during this visit. The orders from Kaiser dated 12/08/2022 identified an unstageable wound on the left heel, and other discharging orders stating that R1 needs "intermittent skilled nursing care, physical therapy and /or speech therapy."

The service plan dated 1/4/2022 identified in the appeal was signed on 12/28/2022; 11 months after the visit by the department on 12/28/2022.

Citation given on this day for Exceptions for Health Conditions and Prohibited Health Condition on the attached 809 D page.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/06/2023 05:20 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: 10/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
10/07/2023
Section Cited
CCR
87616(a)

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87616 Exceptions for Health Conditions (a) As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means.
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Licensee agrees to submit a request for an exception to retain any resident that has a prohibited health condition. Licensee shall review the regulation on prohibited health condition and submit a statement of understanding of this regulation.
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This requirement was not met as evidenced by records reviewed and interviews conducted the facility admitted R1 without an exception or without requesting an exception.
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The plan should be submitted by POC date.
Request Denied
Type A
10/07/2023
Section Cited
CCR87615(a)(1)

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Prohibited Health Condition 87615(a)(1) Persons who require health services or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Stage 3 and 4 pressure injuries.

This requirement is not met as evidenced by:
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Licensee shall review the regulation on prohibited health condition and submit a statement of understanding of this regulation.
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Based on interviews and records review it was determined that Licensee/Administrator retained R1 at the facility and R1 suffered from an unstageable pressure injury. Based on interviews and record reviewed the licensee failed to comply with the cited regulation, by retaining R1 in the facility with an unstageable pressure injury.
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The plan should be submitted 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: 10/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3