502701357-6-9-2026-27-AS-APAA-DUVSJS-20260609135538

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701357
Report Date: 06/09/2026
Date Signed: 06/09/2026 01:55:59 PM

Document Has Been Signed on 06/09/2026 01:55 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	ASPEN VILLE CO		FACILITY NUMBER:	502701357
ADMINISTRATOR/ DIRECTOR:	KAUR, KASHMINDAR		FACILITY TYPE:	740
ADDRESS:	5412 KIERNAN AVENUE		TELEPHONE:	(646) 416-1430
CITY:	SALIDA	STATE: CA	ZIP CODE:	95368
CAPACITY: 32		CENSUS: 31	DATE:	06/09/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Kashminder Kaur		TIME VISIT/ INSPECTION COMPLETED:	02:15 PM

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	At 9:00am on 06/09/2026, Licensing Program Analysts (LPAs) Arielle Pascua and Sulma Lopez arrived unannounced to this facility to conduct an annual visit. LPAs met with Staff Member (SM), Karen Langley and explained the purpose of the visit. LPAs asked SM Langley to conduct the Facility Designated Administrator (FDA), Kashminder Kaur to inform her that CCL was present at this time. At 10:15am, FDA Kaur arrived at the facility to meet LPA. Current census was 31. A brief interview with FDA Kaur was conducted. This facility is licensed to serve 32 residents 60 and older who may be non-ambulatory. This facility also holds a dementia plan on file and a hospice waiver for 32 residents. LPAs Pascua and Lopez reviewed 6 resident files and 6 staff files. It was observed that 6 out 6 residents had an incomplete LIC625, Needs and Services Plan. 1 out 6 resident files revealed that a physician report was not signed by the physician. In addition, it was observed that 1 out of 6 staff files did not have a health screening conducted 6 months prior to their hire date. FDA Kaur has an active administrator certificate #7024979740 and expires on 08/29/2027. LPAs also followed up on an incident report received by the department on 1/07/2026. It was stated that on 01/06/2026, Resident 1 (R1), left the facility through the side gate and was found outside of the facility sitting in on the sidewalk in a nearby neighborhood. It was learned that staff was attending to another resident during this time and did not observed R1 leaving through the side gate. A review of the residents physician report conducted on 06/02/2025 reveals that the resident is unable to leave the facility unassisted. The facility has conducted a fire drill log on 03/12/2026. Fire extinguishers observed were services by the local fire company on 04/10/2026. A tour of the facility was conducted. A tour of the residents rooms were conducted. Furniture and furnishings were sufficient to meet resident needs.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Arielle Pascua
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/09/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ASPEN VILLE CO	FACILITY NUMBER: 502701357
	VISIT DATE: 06/09/2026

NARRATIVE

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A tour of the resident bathrooms were conducted. Hot water temperature was taken in bedrooms 4,5,8,11 and 12 to ensure it was within 105-120 degrees F.
A tour of the resident shower were conducted, grab bars were present and in good repair.
A tour of the laundry room was conducted. Extra linen along with laundry supplies were identified.
A tour of 2 storage units were conducted. Toxins and other cleaning supplies were locked and made inaccessible to residents in care.
This facility has a medication room. Along with personnel responsible for Medication administration, LPAs reviewed and compared Medication to Medication Administration Logs. First Aid kit was present and contained all the required components.
A tour of the kitchen was conducted. It was observed that the facility obtained food delivery as of this date. This facility was observed to have 2-day perishable food supply, however did not have 7 day non-perishable food supply. LPAs observed 8 cans of oatmeal, 9 cans of fruit, 3 cans of beans, 6 cans of tomato soap, seasonings, 2 bags of rice, 3 bags of pasta, 3 containers of jello, a large box of lays, 12 bags of cereal. LPA Pascua discussed with FDA Kaur if this was a sufficient supply of non-perishable food for 32 residents. FDA Kaur stated no.
A tour of the yard was conducted. Perimeter fence and gates were in good repair. It was learned that the facility installed a delayed egress gate facing the main road. It was stated that the fire inspector had already approved this gate, however, the department was not notified of the change to the facility. LPA Pascua advised that the facility go through the proper protocols when making any changes to the facility. LPA Pascua requested a LIC200 and updated facility sketch to request an updated fire clearance.
The following documents were requested for review by this LPA:
-LIC308
-LIC400
-LIC500
-LIC610E

An immediate civil penalty is being issued of $500 for Section 87411(a).

Per California Code of Regulations (CCR) – Title 22 – Division 6, Chapter 6, deficiencies were observed during today’s visit. Citations can be found on the LIC 809 D. Failure to correct deficiencies may result in civil penalties. Appeal Rights were provided to FDA Kaur. An exit interview was held, and a copy of the report was provided in-person.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Arielle Pascua
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/09/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/09/2026 01:55 PM - It Cannot Be Edited

Created By: Arielle Pascua On 06/09/2026 at 01:25 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ASPEN VILLE CO	FACILITY NUMBER: 502701357
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87412(a)(11)

Personnel Records

(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: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by not ensuring that 2 out 6 staff members obtained a health screening prior to employment. This poses an immediate health, safety and personal rights risks to persons in care.
	POC Due Date: 06/10/2026
	Plan of Correction
1 2 3 4	Administrator states that an updated health screening will be conducted for 2 out 6 staff members. A statement of corrections wil be provided to the LPA highlighting best practices in obtaining proper health screening by POC date.

Type A

Section Cited

CCR

87555(b)(26)

General Food Service Requirements

(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above by not ensuring there was a sufficient amount of 7 day non-perishable food supply for 32 residents. This poses an immediate health, safety, and personal rights risks to persons in care.
	POC Due Date: 06/10/2026
	Plan of Correction
1 2 3 4	Administrator states that the facility will obtain extra groceries by POC date. A picture as well as receipt will be provided to the LPA. A statement of correction will be provided to the LPA by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:

	Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/09/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/09/2026 01:55 PM - It Cannot Be Edited

Created By: Arielle Pascua On 06/09/2026 at 01:29 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ASPEN VILLE CO	FACILITY NUMBER: 502701357
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87411(a)

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and records review, the licensee did not comply with the section cited above by not ensuring there was a sufficient amount of staff to ensure that R1 did not leave the facility unassisted. This poses an immediate health, safety, or personal rights risks to persons in care.
	POC Due Date: 06/10/2026
	Plan of Correction
1 2 3 4	An immediate civil penalty of $500 was issued for violation of this Section. Licensee will provide a statement of correction, along with proof of training from an outside vendor for no less that one hour in duration regarding AWOL procedures. Licensee shall also update AWOL procedures. A copy of training and these procedures shall be provided to to the LPA by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:

	Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/09/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/09/2026 01:55 PM - It Cannot Be Edited

Created By: Arielle Pascua On 06/09/2026 at 01:34 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ASPEN VILLE CO	FACILITY NUMBER: 502701357
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87457(c)(3)

(3) The prospective resident, or his/her responsible person, if any, shall be involved in the development of the appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by not ensuring that 6 out 6 residents needs and services plan were conducted with and signed by the resident or their responsible party. This poses a potential health, safety, and personal rights risks to persons in care.
	POC Due Date: 06/30/2026
	Plan of Correction
1 2 3 4	Administrator states that the facility will obtained signing the updated Needs and Services plans. A statement of correction will be provided to the LPA by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:

	Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/09/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2026

LIC809 (FAS) - (06/04)

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