Complaint Investigation Report

565801215-8-25-2023-29-AS-DPEA-CV6PAF-20230829110841

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office , 21731 VENTURA BLVD. #250

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

05/18/2023 and conducted by Evaluator Zabel Chochian

COMPLAINT CONTROL NUMBER: 29-AS-20230518095544

Correct refund was not issued to resident's authorized representative

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver investigation finding. Reason for visit was explained. Staff contacted Administrator. LPA discussed the above allegation investigation finding with Administrator.

Investigation into this allegation consist of records review on 5/19/2023 and 8/22/2023; interview with administrator and staff 5/19/2023; interview with responsible person on 6/23/2023 and 8/22/2023. Based on records reviewed and interviews conducted it was revealed R1 was admitted to facility in late December 2022 with a level 4 monthly services fee of $4500. R1 was assessed to be at level 5 sometime in 2/2023 which increased monthly service fee to $5500. R1's 3/2023 monthly service fee of $5500 was paid in full. R1 passed away at the facility on 3/10/2023. R1's belongings were removed 03/13/2023. A refund of $2250 was issued however this is not the correct refund amount. A refund is due for 18 days (3/14/2023 - 3/31/2023) as follows: $5500/31=$177.42 per day; 18 days x 177.42 =$3,193.56.

Based on information obtained, the allegation is substantiated at this time.

Citation issued (see attached LIC 9099-D). Exit interview conducted. Copy of report and appeal rights issued.