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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366423704
Report Date: 09/05/2023
Date Signed: 09/05/2023 11:46:42 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/10/2020 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20201210110931
FACILITY NAME:AASPEN VILLAGECARE IIFACILITY NUMBER:
366423704
ADMINISTRATOR:MUSHTAQ KHANFACILITY TYPE:
740
ADDRESS:7645 KICKAPOO TRAILTELEPHONE:
(760) 365-6338
CITY:YUCCA VALLEYSTATE: CAZIP CODE:
92284
CAPACITY:15CENSUS: 10DATE:
09/05/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lora Statler, House Manager TIME COMPLETED:
11:55 AM
ALLEGATION(S):
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Staff are falsifying facility's records.
Medications are not given as prescribed
Staff failed to seek medical treatment for resident in a timely manner.
Staff handled resident in a rough manner, causing bruising.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegation(s) noted above. LPA met with Lora Statler, House Manager. Administrator Christopher Tanabe was available via telephone. and explained the purpose of the visit and the elements of the allegation(s). The allegation was investigated, the investigation consisted of observation, interviews and record review.

Staff are falsifying facility's records.

The allegation noted above was investigated by the Department; Facility documentation was reviewed, and interviews were conducted; the following was revealed; It is alleged that facility were not dispensing resident medications as prescribed by their physician. Investigation revealed that facility staff had been entering their initials in the Medication Administration Records (MAR) sheet, which monitors and logs when medication has been dispensed. Entering initials into this MAR sheet acknowledges that the staff *** Continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
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 8
Control Number 18-AS-20201210110931
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: AASPEN VILLAGECARE II
FACILITY NUMBER: 366423704
VISIT DATE: 09/05/2023
NARRATIVE
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has dispensed and that the resident has received medication as prescribed by the physician. According to training received by facility staff; When staff arrive for their shift, the staff is to review the MAR sheet, and both the arriving and departing staff should sign off acknowledging that the MAR sheets are accurate. However, LPA found that there were several times where staff reported signing upon arrival for their shift and the departing staff had already signed, noting a discrepancy and a false claim. Therefore, the allegation Staff are falsifying facility's records is SUBSTANTIATED.

Medications are not given as prescribed.
The allegation noted above was investigated by the Department; Facility documentation were reviewed, and interviews were conducted; the following was revealed; Upon reviewing Resident #4 (R4) file, prescription notates that R4 can have Baclofen three times a day as needed. However, on the Medication Administration Records (MAR) sheet, documents that R4 can only have the medication once a day. R4 also had a prescription for an antibiotic that was written on January 2, 2021, and as of January 6, 2021, R4 had not received the prescribed medication. Staff explanation was that they were too busy to fill the prescription; the staff’s employment was subsequently terminated soon after this information was revealed. As a result, the facility staff failed to dispense medications as prescribed by physician. The allegation of medications are not given as prescribed is SUBSTANTIATED.

Resident(s) toileting needs not met-Left sitting/laying soiled clothing.

LPA reviewed pertinent documents and conducted interviews with staff that indicated that they were not comfortable with things that were happening at the facility such as the overnight staff allegedly sleeping for the most of their shift. Such as sleeping instead of checking on resident’s is a contributing factor of the residents not being changed. Per feedback provided from staff interviews; Staff were reporting for their shift, the call button would be going off, would conduct their initial checks and would find as many as three residents completely soiled in their urine or feces or both. Therefore, the allegation of Residents toileting needs not met-Left sitting/laying soiled clothing Is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 18-AS-20201210110931
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: AASPEN VILLAGECARE II
FACILITY NUMBER: 366423704
VISIT DATE: 09/05/2023
NARRATIVE
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Neglect/Lack of Care and supervision: Facility staff failed to provide resident #1 with timely medical care.


The allegation noted above was investigation by the Department; facility documentation was reviewed, and interviews were conducted. The following was revealed; On September 22, 2020, it is noted in Resident #1 (R1) log, that R1 was noted to be hardly breathing, white foam coming out of the resident’s mouth, unable to swallow, gagging and appeared to be choking. Staff #1 (S1) stated that hospice had been called in an effort to assist the resident during this incident. With R1 being a hospice patient, it is the expectation for hospice to be notified first in case of an emergency and or change of condition. However, the hospice agency denies that they were ever contacted for this incident.

Although, Hospice had come to the facility on the same date as the mentioned incident; this was for regularly scheduled visit and not for a change of condition, as stated by the facility staff. Per the hospice documentation reviewed dated September 22, 2020, the Nurse was at the facility from 8:45am-10:45am, care was provided to R1 (lotion, massage, bed bath, grooming, dressing). There was nothing documented supporting/referring to a change in R1s condition. R1 was described as very agitated and restless at the time of the hospice visit. The facility staff # 1(S1) failed to seek medical treatment for the resident in a timely manner. As a result, the allegation facility staff failed to provide R1 with timely medical care is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted and copy of this report, 9099D and appeal rights were provided to Lora Statler, House Manager
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 18-AS-20201210110931
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: AASPEN VILLAGECARE II
FACILITY NUMBER: 366423704
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/20/2023
Section Cited
CCR
87207
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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
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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.
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medcation was actually given not knowing if the medication was actually given to the resident as prescribed.
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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.
Type B
09/20/2023
Section Cited
CCR
87465(a)(2)
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(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
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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.
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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.
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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.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 18-AS-20201210110931
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: AASPEN VILLAGECARE II
FACILITY NUMBER: 366423704
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/20/2023
Section Cited
CCR
87465(a)(2)
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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:

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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.
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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.
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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.
Type B
09/20/2023
Section Cited
CCR
87465(a)(2)
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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.
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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.
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 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.
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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.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/10/2020 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20201210110931

FACILITY NAME:AASPEN VILLAGECARE IIFACILITY NUMBER:
366423704
ADMINISTRATOR:MUSHTAQ KHANFACILITY TYPE:
740
ADDRESS:7645 KICKAPOO TRAILTELEPHONE:
(760) 365-6338
CITY:YUCCA VALLEYSTATE: CAZIP CODE:
92284
CAPACITY:15CENSUS: 10DATE:
09/05/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lora Statler, House Manager TIME COMPLETED:
11:55 AM
ALLEGATION(S):
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Questionable Death
Staff chemically restrained resident in care.
Staff handled resident in a rough manner, causing bruising\
Residents bathing needs not met.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegation(s) noted above. LPA met with Lora Statler, House Manager. Administrator Christopher Tanabe was available via telephone. and explained the purpose of the visit and the elements of the allegation(s). The allegation was investigated, the investigation consisted of observation, interviews and record review.

Questionable Death.

The allegation noted above was investigation by the Department; Facility documentation were reviewed, and interviews were conducted; the following was revealed; After a review of R1s prescribed medication, R1 was prescribed Fentanyl and Morphine. LPA also reviewed medication related documentation, such as Hospice agency prescription/dosage log along with the facility Medication Administration Record (MAR) as well as the PRN (as needed) logs. ***Continued on 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 18-AS-20201210110931
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: AASPEN VILLAGECARE II
FACILITY NUMBER: 366423704
VISIT DATE: 09/05/2023
NARRATIVE
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It was determined that the facility administered the medication accurately. During an interview conducted with the RN Executive Director from the hospice agency, stated that because “the amount of levels prescribed of both the morphine and Fentanyl would not cause for someone to overdose. If there were to be an overdose of the medications it would not cause foaming at the mouth but a highly sedated state.” Therefore, the allegation of Questionable Death is UNSUBSTANTIATED.

Staff chemically restrained resident in care.
The allegation noted above was investigation by the Department; Facility documentation were reviewed, and interviews were conducted; the following was revealed; LPA reviewed medication related documents, such as Hospice agency prescription/dosage log along with the facility Medication Authorization Record (MAR) as well as the PRN (as needed) logs. R1 was prescribed Morphine (1ml/1h PRN), Temazepam 15 mg at night, repeat 1 every hour if it is ineffective, and Fentanyl (50mcg every 72 hours). It was determined that the facility administered the medication accurately. After record review Medication was given according to the prescription label. Therefore, the allegation of Staff chemically restrained resident in care is UNSUBSTANTIATED.

Staff handled resident in a rough manner, causing bruising. The allegation noted above was investigation by the Department; Facility documentation were reviewed, and interviews were conducted; the following was revealed, LPA reviewed pertinent documents, such as photos that show that Resident #3 R3 did have multiple bruising going down their arm ending at just above the ending of resident’s, index and middle fingers bruising however the bruising was unexplained. Administrator Christopher states that the staff did not report the bruising and had not been made aware until LPA inquired. There was nothing notated in resident’s log for the months of October and November 2020 regarding the bruising. Per resident’s Physician report dated 01/05/18, R3 was not considered to be a fall risk. Administrator Chris did state that prior to R3’s death R3 was a moderate fall risk. It was reported that there was a staff that allegedly caused the bruising and was fired as a result. However, per the Licensee, Mushtaq Khan denied that the reason for terminating the staff’s employment had anything to do with the staff handling R3 in a rough manner, it was for an unrelated matter. Therefore, the allegation of Staff handled resident in a rough manner, causing bruising is UNSUBSTANTIATED.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 18-AS-20201210110931
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: AASPEN VILLAGECARE II
FACILITY NUMBER: 366423704
VISIT DATE: 09/05/2023
NARRATIVE
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Residents not being assisted with bathing needs.

LPA reviewed pertinent documents such as hospice notes and resident observation logs, and conducted interviews with staff revealed that staff denied not assisting any residents with their bathing needs. Resident #1 (R1) is noted to have bathing from both the home health aide as well as the facility staff. Based on interviews and record review the allegation of residents note being assisted with bathing needs is UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time.

An exit interview was conducted and a copy of this report was provided to Lora Statler, House Manager.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 8