ASPEN VILLA

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in five out of five resident bathrooms which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/03/2025 Plan of Correction Adminstrator stated that a video recording of the five resident bathrooms and the Acknowledgement of Understanding of the said deficiency will be submitted to LPA via email by POC due date.

Official classification

Type B

Official code

87303(e)(5)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation made during a tour of the physical plant, the licensee did not comply with the section cited above as neither of the two bathrooms in use to provide toileting care to residents are equipped with slip mats as residents are typically using a shower chair. This however poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/26/2024 Plan of Correction Licensee will acquire slipe mats and provide proof of purchase to LPA before the plan of corrections due date.

Official classification

Type B

Official code

87608(a)

Regulation authority

CCR

What the official deficiency says

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and records reviewed, the licensee did not comply with the section cited above as one bed was observed to be equipped with full rails in spite of the resident not being on hospice and two other residents' beds have half rails without physician orders on file. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/26/2024 Plan of Correction Licensee will proceed to obtain medical orders for half rails for all three residents who require postural supports. Orders will be provided to LPA before the plan of corrections due date.

Official classification

Type B

Official code

87618(b)(3)(B)

Regulation authority

CCR

What the official deficiency says

(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as one resident is being provided oxygen in the absence of any posted signage which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/26/2024 Plan of Correction Licensee purchased adequate signage during the visit and will provide LPA with proof of installation prior to the plan of corrections due date.

Official classification

Type B

Official code

87705(c)(6)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals. This requirement is not met as evidenced by: Deficient Practice Statement Based on records reviewed during the facility visit, the licensee did not comply with the section cited above in one instance as a resident diagnosed with dementia has not been medically assessed since 2021 in spite of the yearly update requirement. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/26/2024 Plan of Correction License reached out to the resident's primary care provider during the visit to obtain an updated physician report. Upon completion of the assessment, a copy will be provided to LPA before the plan of corrections due date.

Official classification

Type A

Official code

87411(g)(1)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General. Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:Obtain a California clearance or a criminal record exemption as required by law or Department regulations.. This requirement was not met as evidenced by: Based on file review and interview, the Facility missed to ensure that employee obtained a California clearance prior to employment. As verified with Administrator (AD), Staff 2 did not have a California criminal record clearance on file prior to employment. Hire date was April 17, 2021. This posed immediate threat on the safety the residents in care.

Official plan of correction

Administrator removed Staff 2 on the floor and sent staff for fingerprint scan. Immediate threat was reduced. AD stated to keep Staff 2 out of the facility until clearance was received. AD agreed to ensure all staff to obtain background clearances prior to employment or initial presence in the facility. (Please see continuation below) AD will provide copy of the clearance to Community Care Licensing Division (CCLD) as soon as the document becomes available or before 5:00 PM of 09/24/2021. Civil penalty was assessed.

Deadline recorded: Sep 16, 2021. A deadline is not proof that correction was completed.