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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700746
Report Date: 08/16/2021
Date Signed: 08/16/2021 11:12:42 AM

Document Has Been Signed on 08/16/2021 11:12 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ASPIRE RESIDENTIAL CARE, LLCFACILITY NUMBER:
392700746
ADMINISTRATOR:FARKAS, KHANHFACILITY TYPE:
740
ADDRESS:121 MCKELVEY AVENUETELEPHONE:
(209) 834-7359
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 3DATE:
08/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH:Theresa MarcosTIME COMPLETED:
11:15 AM
NARRATIVE
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On 8/16/21 at 9:31am, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA was greeted by lead caregiver Theresa Marcos. The administrator Knanh Farkas was not present but gave permission for lead caregiver to sign necessary paperwork and accommodate LPA. LPA explained the purpose of the visit.

LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed facility with a current census of 3. Facility has 4 bedrooms and 2 bathrooms . There is a dining room off the kitchen area. LPA also conducted the infection control domain tool.
The facility submitted a LIC 808 mitigation plan. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and outside. 30-day supply of PPE observed. Bathrooms contained adequate soap, paper towels (in dispenser), and foot pedal garbage can. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.
Water temperature reads 110.6*F in the bathroom and room temperature reads 75*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 2/20/21. Facility has an emergency food and water kit.

Per California Code of Regulations, Title 22, deficiencies were observed during this visit has noted on LIC 809D. Exit interview was held and a report was given to lead caregiver Theresa Marcos.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/16/2021 11:12 AM - It Cannot Be Edited


Created By: Michael Bilger On 08/16/2021 at 10:47 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ASPIRE RESIDENTIAL CARE, LLC
FACILITY NUMBER: 392700746

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(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: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review the licensee did not comply with the section cited above in 2 out of 3 resident charts reviewed. Resident1 (R1) and R2 beds were observed to have half rails attached to their beds with no physician's orders present in their charts which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/20/2021
Plan of Correction
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Licensee will obtain physician orders for half rails for R1 and R2 and submit copies of orders to LPA by POC due date.

Licensee will read section 87608(a)(3) and submit a signed statement of understanding regulation to LPA by POC due date
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2021


LIC809 (FAS) - (06/04)
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