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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701357
Report Date: 01/13/2025
Date Signed: 01/13/2025 03:02:49 PM

Document Has Been Signed on 01/13/2025 03:02 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/
DIRECTOR:		KAUR, KASHMINDARFACILITY TYPE:
740
ADDRESS:5412 KIERNAN AVENUETELEPHONE:
(646) 416-1430
CITY:SALIDASTATE: CAZIP CODE:
95368
CAPACITY: 32CENSUS: 29DATE:
01/13/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Administrator Kaur Kashminder TIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct a case management visit. LPA met with Administrator Kaur Kashminder and explained purpose of visit. Census: 29

LPA Lund came to do a health and safety check on four residents that moved from another facility. LPA Lund interviewed the four residents and reviewed resident files which have all required documentation. Residents’ medications are in compliance. LPA Lund observed that the residents has transitioned to the new facility.



No deficiencies cited on today's visit and copy of report left.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2025
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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