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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700746
Report Date: 09/26/2023
Date Signed: 09/26/2023 03:55:06 PM

Document Has Been Signed on 09/26/2023 03:55 PM - 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: 4DATE:
09/26/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Maria HinautanTIME COMPLETED:
04:00 PM
NARRATIVE
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On 9-26-23, LPA Michael Bilger arrived unannounced to conduct a case management visit regarding medication documentation and caregiving practices. LPA met with lead caregiver Maria Hinautan and explained the purpose of the visit. LPAs Bilger and Villanueva reviewed medication log sheets for August 2023 as part of a record review for complaint #27-AS-20230816132021 . LPAs also conducted interviews with four staff members and reviewed needs and service plans and appraisals for resident1 (R1), R2, R3, and R4.

Based on interviews and record reviews, it was determined that a physician’s order for resident2 (R2) is written as Trazodone HCL 150 milligrams (mg) to be taken at 8:00pm daily. LPAs review of medication log sheets indicate this medication was not administered on 8-19-23 as staffing initials were not present to indicate such.

Additionally, LPA Bilger conducted a facility observation on 9-21-23 related to complaint # 27-AS-20230816132021. LPA also conducted interview with caregiver on duty. Based on observations, interviews, and record reviews it was determined that R1 and R3 require one on one (1:1) monitoring all or most of the time. Additionally, it was determined through record review that R2 requires 2-person assist with bathing and toileting. Interviews and observations revealed only 1 caregiver is on duty per shift including 9-21-23 during LPA’s visit. Furthermore, it was revealed during interview, that R2 has been told to eliminate self in R2’s diaper due to 1 staff on duty and wait until the relief staff for the next shift comes on duty to assist.

As a result of today’s case management, citations are issued under Title 22, Division 6 and indicated on LIC 809D. An exit interview was conducted with Maria Hinautan and a copy of this report was left with Maria. LIC 811 and appeal rights provided.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 09/26/2023 03:55 PM - It Cannot Be Edited


Created By: Michael Bilger On 09/26/2023 at 02:00 PM
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: 09/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/27/2023
Section Cited
CCR
87468.1(a)(3)

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87468.1(a)(3) Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions…such as…interfering with daily living functions such as…elimination. This requirement was not met as evidenced by:
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Licensee will ensure completed staff training on personal rights of residents. Training date to be submitted to LPA by POC due date. Proof of completed training to be submitted to LPA no later than 2 weeks from date of citation issuance.
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Based on interview, Licensee is not adhering to resident rights as stated above in that R2 has been told to eliminate self in diaper due to only 1 caregiver on duty to assist. This poses an immediate health, safety, and resident rights risk to residents in care.
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Licensee will ensure updated training on elder abuse to include but not be limited to: Appropriate care procedures necessary to avoid forms of neglect and humiliation as noted in personal rights Section 87468.1(a)(3). Training date to be submitted to LPA by POC due date. Proof of completed training to be submitted to LPA no later than 2 weeks from date of citation issuance.
Request Denied
Type A
09/27/2023
Section Cited
CCR87405(h)(5)

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87405(h)(5). Administrator Qualifications and Duties. (h) The administrator shall have the responsibility to: (5) Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs, including those services identified in the residents' Pre-Admission Appraisals, specified in Section 87457, Pre-admission Appraisal, and Reappraisal, as specified in Section 87463. This requirement was not met as evidenced by:
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Licensee will read regulation 87405(h)(5) and submit a signed declaration of understanding to LPA by POC due date.
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Based on interview, record review, and observation, Administrator did not provide appropriate staffing solutions to meet the needs of residents as identified on appraisal and needs and service plans. This poses an immediate health and safety risk to residents in care.
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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: 09/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/26/2023 03:55 PM - It Cannot Be Edited


Created By: Michael Bilger On 09/26/2023 at 02:10 PM
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: 09/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
10/06/2023
Section Cited
CCR
87465(a)(4)

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87465(a)(4). Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility… (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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Licensee will ensure completed staff training on assistance with self-administered medication and to include, but not be limited to: Medication documentation and following physician’s orders. Proof of completed training to be submitted to LPA by POC due date.
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Based on record review, Licensee did not ensure receive medication as ordered as indicated by lack of staff initials on medication log sheets. This posed a potential health and safety risk to residents in care.
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Licensee to read regulation 87465(a)(4) and submit a signed declaration of understanding to LPA by POC due date.

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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: 09/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2023


LIC809 (FAS) - (06/04)
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