019200664-3-5-2021-15-AS-KHOS-BYXMYE-20210309090126

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200664
Report Date: 03/05/2021
Date Signed: 03/05/2021 10:07:00 AM

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
05/20/2020 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20200520111811

FACILITY NAME:	COLONIAL ACRES RESIDENTIAL CARE HOME		FACILITY NUMBER:	019200664
ADMINISTRATOR:	SARAH MAY BALINGIT		FACILITY TYPE:	740
ADDRESS:	18905 STANDISH AVENUE		TELEPHONE:	(510) 276-0939
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	20	CENSUS: 14	DATE:	03/05/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Sarah Balingit/Administrator		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Facility failed to issue appropriate refund.

INVESTIGATION FINDINGS:

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On this day, March 5, 2021, Licensing Program Analyst (LPA) Delmundo conducted a tele-visit with Sarah Balingit, administrator, to deliver the findings on the above allegation. LPA informed that due to management directive to telework, LPA is unable to deliver the findings in person.

During investigation, LPA conducted interviews and obtained copies documents. Review of documents revealed resident (R1) passed away on March 16, 2020. R1’s belongings were removed the following day which LPA confirmed with Sarah Balingit. LPA also confirmed with John Ronald Olivarez, licensee, that he received an email in late April 2020 or first week of May 2020 from R1’s responsible person regarding refund. According to licensee, refund was only provided upon receipt of the second email from R1’s responsible person on May 2020. Copy of refund check dated May 16, 2020 was obtained by LPA.

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

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Isaac Taggart	TELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2021

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-20200520111811

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: COLONIAL ACRES RESIDENTIAL CARE HOME	FACILITY NUMBER: 019200664
	VISIT DATE: 03/05/2021

NARRATIVE

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Although licensee gave the refund to R1’s responsible person, the allegation of facility failed to issue appropriate refund is substantiated for failure to provide within 15 days from the removal of R1’s belongings and was only provided after second request by the responsible person.

Deficiency is cited from Title 22 California Health and Safety Code (see 9099D). Any repeat violation within 12-month period may result in civil penalty.

Exit interview conducted. Appeal Rights and copy of this report provided via e-mail.

SUPERVISOR'S NAME: Isaac Taggart	TELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20200520111811

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: COLONIAL ACRES RESIDENTIAL CARE HOME	FACILITY NUMBER: 019200664
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/05/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/19/2021 Section Cited HSC 1569.652(c)	1 2 3 4 5 6 7	§1569.652 Termination of admission agreement upon death of resident......and refunds: (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals,................ if the deceased resident paid the fees, to the	1 2 3 4 5 6 7	Corrected. Refund given to the resident's responsible person.
	8 9 10 11 12 13 14	resident’s estate, within 15 days after the personal property is removed. This requirement is not met as evidenced by: -Based on records review and interviews, the licensee did not comply with the above Regulation by failing to provide the refund in a timely manner which posed potential rights risk.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Isaac Taggart	TELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2021

LIC9099 (FAS) - (06/04)

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