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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701055
Report Date: 05/26/2022
Date Signed: 05/26/2022 04:20:56 PM


Document Has Been Signed on 05/26/2022 04:20 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: 18DATE:
05/26/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Licensee Jasraj BhatiaTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sarah Hurt arrived to conduct an unannounced Case Management - Deficiencies visit on Thursday May 26, 2022 at approximately 03:00 p.m. LPA met with Licensee Jasraj Bhatia and explained the purpose for today's visit.

LPA toured the outdoor and indoor areas of facility including kitchen area, resident bedrooms, and bathrooms. LPA observed kitchen food storage, and spoke with facility kitchen staff. Facility kitchen staff was preparing hamburgers, French fries, and fresh fruit as residents dinner meal. LPA observed a medication technician in the medication room, and two caregivers assisting residents.

Staff 1 appeared to be watering the lawn outside as LPA approached the facility. LPA attempted to communicate with staff 1 but was unable to as there was a language barrier. Staff 1 directed LPA inside to meet with other facility staff. LPA interviewed Licensee Jaraj Bhatia and he explained Staff 1 is fairly new and has been assisting in the kitchen, gardening, and also with resident care. LPA reviewed staff 1's file and he does not have a first aid certificate on file.

The following deficiencies were cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with facility with Licensee Jasraj Bhatia and a copy of this report along with appeal rights was provided.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022
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 05/26/2022 04:20 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: 05/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
06/09/2022
Section Cited

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87411 Personnel Requirements
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. The following requirement has not been met as evidenced by:
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Facility staff 1 does not have first aid certification on file which poses a potential health, safety, or personal rights risk to residents in care.
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Deficiency Dismissed
Type B
06/09/2022
Section Cited

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87411 Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance
(3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.The following requirement has not been met as evidenced by:
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LPA observed facility staff 1 has a language barrier with residents 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: 05/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022
LIC809 (FAS) - (06/04)
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