AASPEN VILLAGECARE II

Official classification

Type B

Official code

87468.2(a)(21)

Regulation authority

CCR

What the official deficiency says

87468.2(a)In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents...shall have all of the following personal rights:(21)To consent to have their relatives and other individuals of their choosing visit during reasonable hours, privately, and without prior notice. This requirement is not met at evidenced by: The licensee did not comply with the section cited above by staff restricting R1’s visits without consent from resident, which poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee/Administrator has agreed to provide staff with inservice training on the regulation cited and submit documentation of training to the licensing agency by POC due date.

Deadline recorded: Feb 18, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(14)

Regulation authority

HSC

What the official deficiency says

87468.1(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(14) To have reasonable access to telephones, to both make and receive confidential calls. This requirement is not met as evidenced by: The Licensee did not comply with the section cited above by facility staff restricting R1’s telephone calls without resident’s consent, which poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee/Administrator has agreed to provide staff with inservice training on the regulation cited and submit documentation of training to the licensing agency by POC due date.

Deadline recorded: Feb 18, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

80087(a)

Regulation authority

CCR

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 and interviews, the administrator/Licensee did not comply with the section cited above by not ensuring facility is free of pests. This violation poses a potential health and safety risk to residents/staff in care

Official plan of correction

Administrator contacted exterminator to notify all residents have been removed from the facility and will schedule a day to return and spray the entire facility. An invoice will be provided to LPA when visit is conducted.

Deadline recorded: Jul 11, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

80087(a)

Regulation authority

CCR

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 and interviews, the administrator/Licensee did not comply with the section cited above by leaving an open hole which also may have black mold in the facility ceiling and not ensuring facility is free of pests. This violation poses an immediate health and safety risk to residents/staff in care

Official plan of correction

Administrator is advised to get the black mold tested , provide proof of invoice/results and patch the open hole in the ceiling and provide proof to LPA by POC due date

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

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

Administrator was advised to discuss with Licensee to submit closer plan and updated eviction notices to be approved by CCLD. Administrator was advised once the closure plan is submitted and approved, eviction dates are reset.

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

Official classification

Type A

Official code

87412(a)(13)(B)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA record review, the licensee did not comply with the section cited above by staff #1 did have have record of criminal record clearance by the department, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/19/2023 Plan of Correction The licensee/Administrator shall submit to the Licensing agency by POC due date, a statement of understanding on regulation cited and an understanding that uncleared staff shall not return to the facility until staff has received a criminal record clearance.

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observations and interviews, the licensee did not comply with the section cited above by facility did not maintain record of liability insurance , which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/12/2024 Plan of Correction Licensee/Administrator shall submit to the licensing agency proof of insurance by POC due date.

Official classification

Type B

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. 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 resident #1 did not have a complete appraisal on file, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/12/2024 Plan of Correction Licensee/Administrator shall submit to the licensing agency proof of completed resident appraisal by POC due date.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA record review, the licensee did not comply with the section cited above by LPA review of staff files reveal, the facility did not maintain record of CPR training for staff #2 (S2), staff #3 (S3), and staff#4 (S4) CPR, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/12/2024 Plan of Correction Licensee/Administrator shall submit to the Licensing Agency record of staff CPR/first aid training.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician...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 facility did not maintain record of staff #1's health screening, did not have recordswhich poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/12/2024 Plan of Correction Licensee/Administrator shall provide proof of staff#1 health screening with tuberculosis results by POC due date.

Official classification

Type B

Official code

87207

Regulation authority

CCR

What the official deficiency says

87207 False Claims No licensee, officer or employee of a license shall make or dissemenate any false or misleading statement regrding the facility or any of the serives provided by the facility. This requirement is not met as evidenced by: by: R1s MARs were signed off before the medcation was actually given not knowing if the medication was actually given to the resident as prescribed.

Official plan of correction

The Licensee agrees to conduct an staff inservice on MARs and the importance of completing the documentation accurately. The POC is due to the department by 5pm on the due date indicated. The Licensee agrees to conduct an staff inservice on MARs and the importance of completing the documentation accurately. The POC is due to the department by 5pm on the due date indicated.

Deadline recorded: Sep 20, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:Based on 1 out of 1 resident was not provided assistance with getting their medical needs met. This poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee agrees to conduct an staff inservice on medication administration. The POC is due to the department by 5pm on the due date indicated. The Licensee agrees to conduct an staff inservice on medication administration. The POC is due to the department by 5pm on the due date indicated.

Deadline recorded: Sep 20, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(2)

Regulation authority

CCR

What the official deficiency says

87465 (a)(1) Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: 1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on 1 out of 1 resident was not provided assistance with getting their medical needs met. This poses a potential health, safety and personal rights risk to persons in care.

Official plan of correction

The Licensee agrees to conduct an staff inservice on when to contact and when to call 9-11. The POC is due to the department by 5pm on the due date indicated. The Licensee agrees to conduct an staff inservice on when to contact and when to call 9-11. The POC is due to the department by 5pm on the due date indicated.

Deadline recorded: Sep 20, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) Residents ina all residential care facilities for the elderly shall have all of the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on 1 out of 1 resident was not provided assistance with getting their bathing needs met. This poses a potential health, safety and personal rights risk to persons in care.

Official plan of correction

The Licensee agrees to conduct an staff inservice on assisting resident with their bathing needs. The POC is due to the department by 5pm on the due date indicated. The Licensee agrees to conduct an staff inservice on assisting resident with their bathing needs. The POC is due to the department by 5pm on the due date indicated.

Deadline recorded: Sep 20, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87412(a)(13)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: 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 allowing Staff 1 to work at the facility without criminal background clearance which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/18/2022 Plan of Correction Administrator immediately removed Staff 1 (S1) at the the facility during the visit. Administrator stated he will submit Statement of Understanding on CCR 87412(a)(13) and submit to LPA Brown by POC due date.

Official classification

Type B

Official code

87303(c)

Regulation authority

CCR

What the official deficiency says

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above by not maintaining four (4) window screens in good repair which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/24/2022 Plan of Correction Administrator stated that they will repair and put back the four (4) window screens and submit prrof of correction to LPA Brown by POC due date.

Official classification

Type B

Official code

30

Regulation authority

HSC

What the official deficiency says

Licensee has provided all staff who are working with Covid-19 positive residents with fit testing for N95 respirators. This practice has a health and safety impact, that includes but is not limited to personal rights, buildings and grounds and responsibility for providing care and supervision. 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 all staff fit tested for N95 respiratorswhich poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/03/2022 Plan of Correction Administrator stated that they will have all staff N95 fit tested and submit proof of completion to LPA Brown by POC due date.