015601219-6-23-2021-15-AS-KHOS-C4PK4D-20210707073409

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601219
Report Date: 06/23/2021
Date Signed: 06/23/2021 02:47:00 PM

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
06/16/2021 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20210616153838

FACILITY NAME:	LAKE MERRITT CARE HOME		FACILITY NUMBER:	015601219
ADMINISTRATOR:	MARIA V. MILARE		FACILITY TYPE:	740
ADDRESS:	576 VALLE VISTA AVENUE		TELEPHONE:	(510) 832-0442
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94610
CAPACITY:	15	CENSUS: 15	DATE:	06/23/2021
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Iris Serrano/Co-administrator and Maria 'Marie' Millare/Licensee-administrator		TIME COMPLETED:	02:55 PM

ALLEGATION(S):

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Financial abuse.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Alicia Delmundo and Carol Fowler arrived unannounced to investigate the above allegation. LPAs met with Iris Serrano, co-administrator, and informed the purpose of visit. Maria 'Marie' Millare, licensee-administrator, arrived after about 30 minutes.

It was alleged that adminstrator, Maria Millare, asked resident to make payment for rent payable to her.

LPA Delmundo reviewed facility file in Community Care :Licensing on June 21, 2021 which revealed the licensee is a corporation with Maria Millare as sole owner and officer.

On this day, June 23, 2021, LPAs obtained copies of LIC9020 Register of Facility Clients/Residents and resident's records, reviewed residents' files and conducted interviews.

....continued on next page (9099C)

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20210616153838

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: LAKE MERRITT CARE HOME	FACILITY NUMBER: 015601219
	VISIT DATE: 06/23/2021

NARRATIVE

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Iris Serrano indicated there's one resident making rent payment payable to Maria Millare which LPAs confirmed with Maria Millare. Maria stated she had one of the resident write a check payable to her, because the resident is having difficulty writing down on the check the whole facility name.

LPAs interviewed residents (R1, R2 and R3) and resident's responsible person (W1). One out of these 3 residents said rent payment is made payable to Marie Millare while the other resident and W1 indicated check payment for rent is payable to Lake Merritt Care Home.

Based on information obtained from interviews and review of facility file, the allegation is unfounded due to the licensee is Maria Millare whose payment of one of the resident is made payable to the licensee's name. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview conducted and copy of this report provided to Iris Serrano.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

LIC9099 (FAS) - (06/04)

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