502701357-11-14-2024-27-AS-KHOS-DBMTGX-20241204134352

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 502701357
Report Date: 11/14/2024
Date Signed: 11/14/2024 08:29:42 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/15/2024 and conducted by Evaluator Jason Lund

COMPLAINT CONTROL NUMBER: 27-AS-20240815070104

FACILITY NAME:	ASPEN VILLE CO		FACILITY NUMBER:	502701357
ADMINISTRATOR:	KAUR, KASHMINDAR		FACILITY TYPE:	740
ADDRESS:	5412 KIERNAN AVENUE		TELEPHONE:	(646) 416-1430
CITY:	SALIDA	STATE: CA	ZIP CODE:	95368
CAPACITY:	32	CENSUS: 23	DATE:	11/14/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Administrator Kaur Kashminder		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility staff not properly addressing cockroaches in the facility
Facility staff not properly addressing flies in the facility
Facility staff not providing food to residents in the quantity necessary
Facility staff not providing drinking water to residents in the quantity necessary
Facility staff not ensuring facility is maintained in good repair resulting in flooding

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to complete a complaint investigation regarding the above allegations. LPA Lund met with Administrator Kaur Kashminder and explained the reason for the visit. Census: 23
Facility staff not properly addressing cockroaches in the facility- LPA Lund reviewed facility records, LPA Lund observations, interviews with staff, and residents in care. Based on reviewed facility records, LPA Lund observations, interviews with staff, and residents in care. LPA Lund observed no cockroaches throughout the facility during visits on 5/23/2024, 8/21/2024, and 11/14/2024. LPA Lund reviewed facility records from Peace of Mind Pest Control Inc from 11/15/2023 through 4/22/2024 stating that facility was addressing any pest control issues including cockroaches. Staff interviewed stated that never seen any cockroaches inside the facility. Residents interviewed stated that never seen any cockroaches at all.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

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 3

Control Number 27-AS-20240815070104

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ASPEN VILLE CO	FACILITY NUMBER: 502701357
	VISIT DATE: 11/14/2024

NARRATIVE

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Based on reviewed facility records, LPA Lund observations, interviews with staff, and residents in care, on the information provided, it was unclear if facility staff not properly addressing cockroaches in the facility, therefore the allegation was deemed UNSUBSTANTIATED.
Facility staff not properly addressing flies in the facility- LPA Lund reviewed facility records, LPA Lund observations, interviews with staff, and residents in care. Based on reviewed facility records, LPA Lund observations, interviews with staff, and residents in care. LPA Lund observed fly lights throughout the facility and no flies during visits on 5/23/2024, 8/21/2024, and 11/14/2024. LPA Lund reviewed facility records from Peace of Mind Pest Control Inc from 11/9/2023 through 4/22/2024 stating that facility was addressing any pest control issues including flies. On 10/23/2023 the facility installed fly lights in the kitchen area and on 11/1/2023 installed two lights in the dinning area and one more in the kitchen area. Staff interviewed stated that the facility has installed fly lights and has help addressing any issues with flies. Residents interviewed stated that flies have never been a problem at the facility.
Based on reviewed facility records, LPA Lund observations, interviews with staff, and residents in care, on the information provided, it was unclear if facility staff not properly addressing flies in the facility, therefore the allegation was deemed UNSUBSTANTIATED.
Facility staff not providing food to residents in the quantity necessary- LPA Lund reviewed facility records, interviewed staff, and residents in care. Based on interviews with staff, residents in care, and facility records reviewed. LPA Lund reviewed Spring and Summer 2024 breakfast, lunch and dinner menus from the facility with sufficient food items for the residents in care. LPA Lund reviewed food orders dated 8/12/2024 and 8/19/2024 with enough quaintly necessary to feed the residents in care. LPA Lund observed 2- day perishable and 7- day nonperishable, during visits on 5/23/2024, 8/21/2024, and 11/14/2024. Residents interviewed stated that food from the facility was good and they get enough food.
Based on facility records review, interviews with staff, residents, on the information provided, it was unclear if facility staff not providing food to residents in the quantity necessary, therefore the allegation was deemed UNSUBSTANTIATED.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20240815070104

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ASPEN VILLE CO	FACILITY NUMBER: 502701357
	VISIT DATE: 11/14/2024

NARRATIVE

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Facility staff not providing drinking water to residents in the quantity necessary- LPA Lund interviewed staff, and residents in care. Based on interviews with staff, and residents in care. Staff stated that they ask residents through out day if they would like something to drink. Residents interviewed stated that they get enough to drink.
Based on interviews with staff, and residents in care, on the information provided, it was unclear if facility staff not providing drinking water to residents in the quantity necessary, therefore the allegation was deemed UNSUBSTANTIATED.
Facility staff not ensuring facility is maintained in good repair resulting in flooding- LPA Lund reviewed facility records and observed, interviewed staff, and residents in care. Based on interviews with staff, residents in care, and facility records reviewed and LPA Lund observations. LPA Lund reviewed records from Tony’s Plumbing from 10/18/2023 through 3/26/2024. On 3/26/2024 Tony’s Plumbing was called out to fix two toilets that were backed up. They were fixed on 3/26/2024 by Tony’s Plumbing. Staff interviewed stated that the facility has maintenance that will fix any issues with the facility. Residents interviewed stated they have never had any problems with the plumbing. LPA Lund observed during visits on 5/23/2024, 8/21/2024, and 11/14/2024 were clean and in good repair.
Based on facility records review and LPA Lund observations, interviews with staff, and residents, on the information provided, it was unclear if facility staff not ensuring facility is maintained in good repair resulting in flooding, therefore the allegation was deemed UNSUBSTANTIATED.
As a result of this investigation, this Department finds the allegation to be UNSUBSTANTIATED. A complaint allegation finding of 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 occurred. Exit interview conducted and report left.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

LIC9099 (FAS) - (06/04)

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