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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700746
Report Date: 01/18/2022
Date Signed: 01/18/2022 10:21:05 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/28/2021 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20211228151714
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: 4DATE:
01/18/2022
UNANNOUNCEDTIME BEGAN:
09:29 AM
MET WITH:Khanh FarkasTIME COMPLETED:
10:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not trained
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
{This document is an amendment from the original document recorded 1-5-22 and created on 1-18-22 at 9:29am referring to complaint control #27-AS-20211228151714. Licensing Program Analyst (LPA) Michael Bilger arrived at facility on 1-18-22 at 9:29am and met with Herbiberto Dela Pena, facility manager to explain purpose of LPA's visit. Administrator Khanh Farkas was notified by phone of the purpose of the visit and gave permission for Herbiberto to sign in her absence. An exit interview was conducted an a copy of this report was left with Herbiberto}. On 1-5-22 at 9:30am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a complaint visit for the allegation noted above. LPA met with caregiver who notified Administrator Khanh Farkas of LPA’s arrival. LPA spoke with Administrator via phone and explained the purpose of the visit. Administrator arrived at facility at 12:10pm. LPA reviewed records for Staff1 (S1), S2, S3, and S4. LPA also interviewed S1, S2, and S3. LPA conducted interviews for Resident1 (R1), R2, R3, and R4. LPA requested facility file documentation including staffing roster, staffing schedule, resident roster, and training records. {Cont. on 9099C}.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/28/2021 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20211228151714

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: 4DATE:
01/18/2022
UNANNOUNCEDTIME BEGAN:
09:29 AM
MET WITH:Khanh FarkasTIME COMPLETED:
10:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not vaccinated
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
{This document is an amendment from the original document recorded 1-5-22 and created on 1-18-22 at 9:29am referring to complaint control #27-AS-20211228151714. Licensing Program Analyst (LPA) Michael Bilger arrived at facility on 1-18-22 at 9:29am and met with Herbiberto Dela Pena, facility manager to explain purpose of LPA's visit. Administrator Khanh Farkas was notified by phone of the purpose of the visit and gave permission for Herbiberto to sign in her absence. An exit interview was conducted and a copy of this report was left with Herbiberto}. On 1-5-22 at 9:30am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a complaint visit for the allegation noted above. LPA met with caregiver who notified Administrator Khanh Farkas of LPA’s arrival. LPA spoke with Administrator via phone and explained the purpose of the visit. Administrator arrived at facility at 12:10pm. LPA reviewed records for Staff1 (S1), S2, S3, and S4. LPA also interviewed S1, S2, and S3. LPA requested facility file documentation including staffing roster, staffing schedule, and vaccination records. Based on interviews conducted and records reviewed, it was determined that all staff have been vaccinated with current vaccination cards on file. Verifications of vaccination cards were noted in staff charts reviewed {Cont. on 9099C}.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20211228151714
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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, LLC
FACILITY NUMBER: 392700746
VISIT DATE: 01/18/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on additional interviews, it was noted that S4 arrives at facility with Administrator as a volunteer, supervised, and without interacting with residents in care. Additionally, a vaccination card for S4 was observed and reviewed by LPA. Based on the interviews and records reviewed, the preponderance of evidence standard is not met, therefore, this allegation is UNFOUNDED. An exit interview was conducted with Khanh Farkas on 1-5-22 and a copy of this report was left with Khanh. .
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20211228151714
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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, LLC
FACILITY NUMBER: 392700746
VISIT DATE: 01/18/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on interviews conducted and records reviewed, it was determined that all staff have received up to date training as indicated by Administrator signature on training records, however, staff signature was not present on training records. Based on additional interviews, it was noted that S4 arrives at facility with Administrator as a volunteer, supervised, and without interacting with residents in care. Based on the interviews and records reviewed, the preponderance of evidence standard is not met, therefore, this allegation is UNSUBSTANTIATED. An exit interview was conducted with Khanh Farkas on 1-5-22 and a copy of this report was left with Khanh.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4