AASPEN VILLAGECARE

Official classification

Type A

Official code

87555(b)(26)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above by not having enough non perishable food supply which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/27/2026 Plan of Correction Administrator/House Manager has agreed to purchase additional non perishables and provide proof to LPA by POC due date

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above Resident #3 (R3) medication is not being administered per physician's orders which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/27/2026 Plan of Correction Administrator/House Manager will provide training to staff and provide proof of understanding regulation to LPA by POC due date.

Official classification

Type B

Official code

87470(c)

Regulation authority

CCR

What the official deficiency says

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above by not having infection control plan accessible for CCLD to audit which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/02/2026 Plan of Correction Administrator/House Manager will provide proof in infection control plan to LPA by POC due date

Official classification

Type B

Official code

87355(e)(4)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above by not having Staff #3 (S3) associated to the facility through guardian which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/02/2026 Plan of Correction Administrator/House Manager will provide proof of association for S3 to LPA by POC due date.

Official classification

Type B

Official code

1569.267(d)

Regulation authority

HSC

What the official deficiency says

(d) The licensee shall provide initial and ongoing training for all members of its staff to ensure that residents’ rights are fully respected and implemented. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above by not having in service training for staff in personnel files which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/02/2026 Plan of Correction Administrator/House Manager has agreed to provide proof of in service trainings to LPA by POC due date.

Official classification

Type B

Official code

87219(d)

Regulation authority

CCR

What the official deficiency says

(d) In facilities licensed for seven (7) or more persons, notices of planned activities shall be posted in a central location readily accessible to residents, relatives, and representatives of placement and referral agencies. Copies shall be retained for at least six (6) months. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above by not having an activities schedule posted which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/02/2026 Plan of Correction Administrator/House Manager has agreed to create and post an activities schedule for residents in care

Official classification

Type B

Official code

1569.695(a)

Regulation authority

HSC

What the official deficiency says

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above by not having an emergency disaster plan accessible to audit which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/02/2026 Plan of Correction Adminstrator/House Manager has agreed to provide the emergency disaster plan to LPA by POC due date

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above by not providing quarterly disaster drills which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/02/2026 Plan of Correction Administrator/House Manager has agreed to conduct a disaster drill with residents and staff and continue to do quarterly and provide proof to LPA by POC due date

Official classification

Type B

Official code

1569.695(f)(2)(D)

Regulation authority

HSC

What the official deficiency says

(f) A facility shall have both of the following in place: (2) A set of keys available to facility staff on each shift for use during an evacuation that provides access to all of the following: (D) All facility cabinets and cupboards or files that contain elements of the emergency and disaster plan, including, but not limited to, food supplies and protective shelter supplies. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above by not having a 72 hour emergency food supply which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/02/2026 Plan of Correction Administrator/House Manager has agreed purchase 72 hour emergency food and provide proof (receipt and photo) to LPA by POC due date

Official classification

Type B

Official code

1569.682

Regulation authority

HSC

What the official deficiency says

1569.682 Transfer of resident upon forfeiture of license or change in use of facility; duties of licensee; closure plan; duty of department upon licensee’s failure to comply; civil penalties(a) A licensee of a licensed residential care facility for the elderly shall, prior to transferring a resident of the facility to another facility or to an independent living arrangement as a result of the forfeiture of a license...or a change of use of the facility pursuant to the department’s regulations, take all reasonable steps to transfer affected residents safely and to minimize possible transfer trauma……..(b) If seven or more residents of a residential care facility for the elderly will be transferred...the licensee shall submit a proposed closure plan to the department for approval. The department shall approve or disapprove the closure plan, and monitor its implementation...(6) Until the department has approved a licensee’s closure plan, the facility shall not issue a notice of transfer or require any resident to transfer. This requirement was not met as evidenced by: Based upon record review and interviews, Administrator/Licensee did not submit closure plan to CCLD for approval. This violation posed a potential health and safety risk to residents in care

Official plan of correction

House Manager Roberts was advised to notify Licensee about office meeting to discuss the status of facilities.

Deadline recorded: Jun 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(a)

Regulation authority

HSC

What the official deficiency says

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. Based on observation the licensee did not comply with the section cited above by leaving room #6 unsanitary with feces on floor and cabinets loose off their hinges in the kitchen which poses an immediate health and safety risk to residents in care

Official plan of correction

House Manager has agreed to clean empty rooms and repair broken cabinets in kitchen by POC due date and submit proof to LPA

Deadline recorded: Jun 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (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 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observations, the licensee did not comply with the section cited above by not ensuring the bathrooms hot water temperature attained at a minimum 105 degree F, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/05/2024 Plan of Correction Licensee/Administrator shall submit to the licensing agency proof of correction by POC due date.

Official classification

Type B

Official code

87307(a)(3)(B)

Regulation authority

CCR

What the official deficiency says

(B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observations, the licensee did not comply with the section cited above by not ensuring the facillty has at a minimum one completely furnished bedroom, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/05/2024 Plan of Correction Licensee/Administrator has submit to the Licensing Agency proof of completely furnished bedroom by POC due date

Official classification

Type B

Official code

87307(d)(2)

Regulation authority

CCR

What the official deficiency says

(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observations, the licensee did not comply with the section cited above by frontyard and backyard of the facilty had overgrown dry shrubs, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/05/2024 Plan of Correction Licensee/Administrator shall submit to the licensing agency proof of yard maintenance by POC due date.