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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 011441040
Report Date: 02/14/2023
Date Signed: 02/14/2023 10:09:37 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/28/2021 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20210528094622
FACILITY NAME:JONES REST HOMEFACILITY NUMBER:
011441040
ADMINISTRATOR:CHARLES W DRAKEFACILITY TYPE:
740
ADDRESS:524 CALLAN AVENUETELEPHONE:
(510) 483-6200
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:31CENSUS: 17DATE:
02/14/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Shirly Solomon, Assisted Living Supervisor TIME COMPLETED:
10:20 AM
ALLEGATION(S):
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Resident was illegally evicted.
INVESTIGATION FINDINGS:
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On 2/14/23 at 9:00AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to deliver finding for the above allegations. LPA met with Shirly Solomon, Assisted Living Supervisor and explained the purpose of the visit.

Allegation - Resident was illegally evicted: During the course of investigation, LPA interviewed S1 on 6/7/21. S1 admitted that there was no written eviction notice to R1 or family member. Facility did not follow appropriate eviction procedures. Therefore, the allegation that resident was illegally evicted is substantiated.
Based on LPAs interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations of Health and Safety Code, is being cited on the attached LIC 9099D.

Exit interview conducted with Assisted Living Supervisor. Appeal Rights and a copy of this report provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023
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 3
Control Number 15-AS-20210528094622
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: JONES REST HOME
FACILITY NUMBER: 011441040
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/24/2023
Section Cited
HSC
1569.683
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1569.683 Eviction notices; reasons for eviction contents; service
(a) In addition to complying with other applicable regulations, a licensee of a residential care facility for the elderly who sends a notice of eviction to a resident shall set forth in the notice to quit the reasons relied upon for the eviction, with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. In addition, the notice to quit shall include all of the following:
(1) The effective date of the eviction.
(2) Resources available to assist in identifying alternative housing and care options, including public and private referral services and case management organizations.
(3) Information about the resident's right to file a complaint with the department regarding the eviction, with the name, address, and telephone number of the nearest office of community care licensing and the State Ombudsman.
(4) The following statement: "In order to evict a resident who remains in the facility after the effective date of the eviction, the residential care facility for the elderly must file an unlawful detainer action in superior court and receive a written judgment
signed by a judge. If the facility pursues the unlawful detainer action, you must be served with a summons and complaint. You have the right to contest the eviction in writing and through a hearing."
(b) The licensee, in addition to either serving a 30-day notice, or seeking approval from the department and serving three days notice, on the resident, shall notify, or mail a copy of the notice to quit to, the resident's responsible person.
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Administrator agrees to review the regulation and submit a self-certification letter to CCL by POC date.
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This requirement was not met as evidenced by: Based on records reviewed and interviewed. Administrator did not follow the proper eviction notices by providing a 30 days notices to R1/ R1 POA. The eviction of R1 does not meet HSC 1569.683 regulation which poses a potential personal rights to persons 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: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/28/2021 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20210528094622

FACILITY NAME:JONES REST HOMEFACILITY NUMBER:
011441040
ADMINISTRATOR:CHARLES W DRAKEFACILITY TYPE:
740
ADDRESS:524 CALLAN AVENUETELEPHONE:
(510) 483-6200
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:31CENSUS: 17DATE:
02/14/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Shirly Solomon, Assisted Living Supervisor TIME COMPLETED:
10:20 AM
ALLEGATION(S):
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Facility failed to provide resident's refund.
INVESTIGATION FINDINGS:
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On 2/14/23 at 9:00AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to deliver finding for the above allegations. LPA met with Shirly Solomon, Assisted Living Supervisor and explained the purpose of the visit.

Allegation: Facility failed to provide resident's refund. During the course of investigation LPA reviewed records of refunded amount that was refunded back to R1 POA that explained the breakdown of the amount that was refunded back to R1 POA which is $284.48.

Base one records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3