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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701055
Report Date: 04/11/2022
Date Signed: 04/12/2022 09:30:08 AM


Document Has Been Signed on 04/12/2022 09:30 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: 18DATE:
04/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Resident Care Coordinator, Karen LangleyTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) conducted a case management visit to the facility on April 11, 2022 at 02:15 p.m. LPA met with Resident Care Coordinator Manisha Punni and explained the purpose of today’s visit.

LPA received a special incident report dated March 18, 2022 related to an incident of suspected abuse at the facility involving Resident 1. On March 11, 2022 Resident 1’s conservator notified Licensee of inappropriate photos taken of Resident 1 by a former home health caregiver at the facility. Resident 1’s conservator informed the facility upon admitting Resident 1 that the staff should be cautious of this home health caregiver while visiting Resident 1 as there has been issues with her in the past but did not disclose details. The facility Administrator did not submit a SOC 341 reporting resident abuse to licensing.

LPA received an incident report dated April 6, 2022 related to Resident 2 climbing the fence. The facility is in the process of putting a plan in place to help Resident 2 with the wandering behaviors. Resident 2 was re assessed by the hospice nurse on April 5, 2022 and given new medications. The facility Resident Care Coordinator stated the medication was prescribed on April 5, 2022 and the physician informed her it would take a week for them to notice it taking effect and reducing the wandering behaviors.

LPA observed the facility does not have any planned activities and no activities staff. LPA suggested more planned activities to help the residents stay busy, and possibly help reduce resident behaviors.

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: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2022
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 3


Document Has Been Signed on 04/12/2022 09:30 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: 04/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/26/2022
Section Cited

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87219 Planned Activities(e)In facilities licensed for sixteen (16) to forty-nine (49) persons, one staff member, designated by the administrator, shall have primary responsibility for the organization, conduct and evaluation of planned activities. This person shall have had at least six (6) months experience in providing planned activities or have completed or be enrolled in an appropriate education or training program.
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The following requirement has not been met as evidenced by: The Licensee does not have any activities staff for the 18 residents living at the facility. The facility currently has no planned activities which poses a potential health, safety, or personal rights risk to residents in care.
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Type B
04/18/2022
Section Cited

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87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.
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This requirement has not been met as evidenced by: The licensee did not submit a SOC341 form reporting suspected resident abuse which poses a potential health, safety, or personal rights risk to 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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3


Document Has Been Signed on 04/12/2022 09:30 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: 04/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/18/2022
Section Cited

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87468.1 Personal Rights of Residents in All Facilities.(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
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The following requirement has not been met as evidenced by: Resident 1 had inappropriate photos of her taken by a visitor which poses a potential health, safety, or personal rights risk to 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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3