502701055-9-14-2022-27-AS-KHOS-CJGQYN-20220921123525

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 502701055
Report Date: 08/29/2022
Date Signed: 09/14/2022 07:30:22 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/29/2022 and conducted by Evaluator Sarah Hurt

COMPLAINT CONTROL NUMBER: 27-AS-20220629142626

FACILITY NAME:	ASPEN VILLE CO		FACILITY NUMBER:	502701055
ADMINISTRATOR:	BHATIA, JASRAJ		FACILITY TYPE:	740
ADDRESS:	5412 KIERNAN AVENUE		TELEPHONE:	(669) 265-4603
CITY:	SALIDA	STATE: CA	ZIP CODE:	95368
CAPACITY:	32	CENSUS: 19	DATE:	08/29/2022
		UNANNOUNCED	TIME BEGAN:	04:15 PM
MET WITH:	Licensee, Jaraj Bhatia		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Resident have been hurt while in care.
Residents are not provided a safe environment.
Residents dietary needs are not being met.
Facility staff does not maintain a comfortable temperature for residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit to the facility on August 29, 2022 to deliver complaint findings. LPA Hurt identified herself and discussed the purpose of the visit with the Licensee Jasraj Bhatia.

Regarding the allegation Resident have been hurt while in care. Based on LPA interviews the residents are no being hurt while in care. LPA interviewed 3 facility caregivers who all stated residents are not being hurt in care. Resident 1 does like to make ornamental fishing hooks, but facility staff place a plastic cover over the hook. The facility staff collect the hook from him when he is done with it to ensure no one is being hurt. Therefore, this complaint is UNSUBSTANTIATED. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Continued on 9099C....

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 27-AS-20220629142626

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/29/2022

NARRATIVE

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.....Continued from 9099

Regarding the allegation Residents are not provided a safe environment. Based on LPA interviews the facility staff is providing a safe environment for residents. LPA interviewed three facility staff who all stated they know the facility residents are safe and being provided good care. The facility staff stated they have not witnessed anything unsafe happening at the facility. Therefore, this complaint is UNSUBSTANTIATED. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation Residents dietary needs are not being met. Based on records reviewed Resident 3’s 602 documents she is on a regular diet. Facility staff stated Resident 3 was a very picky eater and they did attempt to accommodate her food requests. LPA interviewed three facility staff, all stated they make sure residents with special dietary needs are given the correct foods. Therefore, this complaint is UNSUBSTANTIATED. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation Facility staff does not maintain a comfortable temperature for residents. Based on LPA observation the facility is a comfortable temperature. LPA made several unannounced visits to the facility in the past 3 months and each time the facility temperature was comfortable and within regulation. Therefore, this complaint is UNSUBSTANTIATED. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies were cited during this visit Per Title 22 Regulation. Exit interview conducted and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/29/2022 and conducted by Evaluator Sarah Hurt

COMPLAINT CONTROL NUMBER: 27-AS-20220629142626

FACILITY NAME:	ASPEN VILLE CO		FACILITY NUMBER:	502701055
ADMINISTRATOR:	BHATIA, JASRAJ		FACILITY TYPE:	740
ADDRESS:	5412 KIERNAN AVENUE		TELEPHONE:	(669) 265-4603
CITY:	SALIDA	STATE: CA	ZIP CODE:	95368
CAPACITY:	32	CENSUS: 19	DATE:	08/29/2022
		UNANNOUNCED	TIME BEGAN:	04:15 PM
MET WITH:	Licensee, Jaraj Bhatia		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff not providing adequate supervision.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit to the facility on August 29, 2022 to deliver complaint findings. LPA Hurt identified herself and discussed the purpose of the visit with the Licensee Jasraj Bhatia.

Regarding the allegation Staff not providing adequate supervision. Based on records reviewed the facility did not provide adequate supervision for facility Resident 2. Resident 2 eloped from the facility several times. Resident 2 was found at a facility next door and was brought back to the facility by staff. Resident 2’s physicians report states she does have wandering behaviors, but her care plan does not document any plan to prevent these behaviors. Therefore, this complaint is SUBSTANTIATED.

The following deficincies are being cited Per Title 22 Regulations. A copy of this report was provided along with appeal rights.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20220629142626

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/29/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/06/2022 Section Cited CCR 87705(a)(2)	1 2 3 4 5 6 7	87705 Care of Persons with Dementia (a) This section applies to licensees who accept or retain residents diagnosed by a physician to have dementia. Mild cognitive impairment, as defined in Section 87101(m), is not considered to be dementia. (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. The following requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Licensee will conduct training on care plans, and resident supervision with faclity staff and send proof to LPA by POC date of 09/06/2022.
	8 9 10 11 12 13 14	Based on records reviewed Resident 2 eloped from the facility on several occasions which poses a potential threat to the health, safety or personal rights of residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 4