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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701357
Report Date: 05/23/2024
Date Signed: 05/23/2024 02:03:17 PM


Document Has Been Signed on 05/23/2024 02:03 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 COFACILITY NUMBER:
502701357
ADMINISTRATOR:KAUR, KASHMINDARFACILITY TYPE:
740
ADDRESS:5412 KIERNAN AVENUETELEPHONE:
(646) 416-1430
CITY:SALIDASTATE: CAZIP CODE:
95368
CAPACITY:32CENSUS: 30DATE:
05/23/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator Kaur Kashminder TIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct a pre-licensing visit. LPA met with Administrator Kaur Kashminder and explained purpose of visit. The facility capacity is 32 non-ambulatory residents. Census: 30

LPA and Administrator Kaur Kashminder toured/inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2- day perishable and 7- day nonperishable. Fire extinguishers were last serviced on 3/14/2024. Smoke alarms were tested and are operational. The facility has a carbon monoxide detector and performs disaster drills as required. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. The hot water temperature was measured at 112.9*F which is within the required range of 105-120*F.
LPA reviewed 4 staff files and the facility has sufficient staffing to provide the services needed to meet the residents’ needs. All staff have criminal record clearance and are associated to the facility. LPA reviewed 5 resident files & 3 staff files which have all required documents. Component III interview was conducted with Administrator Kaur Kashminder and completed during today's Pre-licensing visit.

No deficiencies observed or cited during today's visit and copy of report left at facility.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024
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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