Complaint Investigation Report

015601083-2-2-2023-15-AS-KHOS-CPGUVY-20230228145556

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office , 1515 CLAY STREET, STE. 310

This is an official report of an unannounced visit/investigation of a complaint received in our office on

12/15/2021 and conducted by Evaluator Grace Luk

COMPLAINT CONTROL NUMBER: 15-AS-20211215150203

Facility did not issue refund to authorized representative.

On 2/2/2023 at 9:10AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegation above. LPA met with Care Coordinator, Bessy John and informed her the reason for the visit.

During the course of investigation, LPA interviewed 2 staff and complainant. Resident's admission agreement, correspondence with R1's POA, procedure on refunds, and care notes were obtained and reviewed. Interview with staff and complainant revealed that R1 moved into the facility on 10/4/2021 and moved out on 11/27/2021. R1's signed admission agreement states if a preadmission appraisal is performed and resident leaves within 60 days, then 60% of preadmission fee will be refunded.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report and appeal rights provided.