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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 041373048
Report Date: 06/24/2022
Date Signed: 06/24/2022 12:17:12 PM


Document Has Been Signed on 06/24/2022 12:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:GISELLE'S CARE HOME #2FACILITY NUMBER:
041373048
ADMINISTRATOR:MEMORACION, ELIZABETHFACILITY TYPE:
740
ADDRESS:2140 CERES AVENUETELEPHONE:
(530) 893-8078
CITY:CHICOSTATE: CAZIP CODE:
95926
CAPACITY:6CENSUS: 0DATE:
06/24/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Licensee Elizabeth MemoracionTIME COMPLETED:
12:30 PM
NARRATIVE
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On 06/24/2022, The Department met with Licensee Elizabeth Memoracion at the Community Licensing Office (520 Cohasset Rd. STE 170, Chico CA 95926) to go over the following:
The Community Care Licensing Division (CCLD) received a complaint. During the Department’s investigation the Department learned, Staff 1 (S1) asked resident 1, (R1) son to pay extra money to S1’s spouse Staff 2 (S2), claiming they provided extra care to the resident. The Department conducted a trust audit and the following are the findings of the Department’s investigation.

Finding 1): The facility’s former manager S1 financially abused a resident.
Facility staff financially abused resident by charging an extra amount of money directly to S1 or/and S1’s spouse, above the $4,000/month paid to the facility. Licensee confirmed R1 already paid for the monthly Board and Care (B&C) indicated on the Admission Agreement (AA), and deposited the checks to the business account. The extra money paid to S1 and S2 were in addition to the B&C and was not legitimate. Licensee stated all care and supervision that R1 needed was included in the facility’s B&C basic services per the AA. It was not S1’s decision if R1 needed more or a higher level of care. S1 and S2’s bank records for the period between March 1, 2020 to December 31, 2021. The records show during the time, multiple checks were made payable to S2 by R1’s responsible party totaling over $49,000. The checks were cashed or deposited to S1 and S2’s joint account. Based on the documentation and information available. S1 and S2 financially abused R1. In addition, they also engaged in embezzlement activities using their positions as manager and staff at the facility to gain trust from responsible party, for unlawful personal gain of a substantial amount of money.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: GISELLE'S CARE HOME #2
FACILITY NUMBER: 041373048
VISIT DATE: 06/24/2022
NARRATIVE
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Finding 2): The licensee failed to notify for rate change and overcharged for B&C

The investigation revealed R1 and responsible party did not receive a rate increase notice because the Admission Agreement (AA) provided by the licensee shows R1’s B&C was $3,800/month when R1 moved in, March 2020. R1’s AA provided by licensee shows two rates, $3,800/month for B&C, initialed by R1’s responsible party, dated March 2020, the following page shows $4,000/month, without initial and signature, and only handwritten on the top of the page, stated rate increase in April 2020. The regulation requires the licensee to provide written notice to the resident’s responsible party within 60 days, which the licensee failed to do. The “updated” AA, with $4,000 B&C, was not signed or initialed by R1’s responsible party. The rate increase is
not valid, R1 was overcharged.

Finding 3): The licensee did not issue refund to resident’s responsible party after the resident moved out of the facility because the facility was closing

Licensee closed out the facility in March 2022 and put the home on the market
for sale. All the residents were relocated. Among the 6 residents, 5 of them were paid
by Far Northern Regional Center or have conservatorship. R1 was the only private pay
resident and R1 moved out on 2/19/2022. R1’s responsible party paid $4,000 for that month and did not receive any refund. Refund to R1's responsible Party is $1,150.00.


Continued on 809-C
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: GISELLE'S CARE HOME #2
FACILITY NUMBER: 041373048
VISIT DATE: 06/24/2022
NARRATIVE
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Finding 4): the facility did not have surety bond required.

The facility handled cash resources for 1 resident. The Regional Center sent Personal &
Incidental (P&I) to Beth every month, $137 to $138 per month for Year 2020 and Year 2021. Because the licensee was handling cash resource, according to regulation, the licensee must carry required surety bond. Beth stated they had a surety bond for $2,000. However, the documentation provided shows the bond was for Giselle’s Care Home 1, with Giselle’s Home 1 property address. In addition, it was canceled April 22, 2022. There is no evidence that Giselle’s Care Home 2 had a required surety bond.

Finding 5): The licensee is out of compliance with cash handling requirements some P&I purchases were not supported by receipts.

The licensee handled cash resources for one resident, Resident 2 (R2). Far Northern Regional Center sent R2’s monthly P&I to Beth, and Beth made purchases for R2.

Beth provided the receipts. The receipts showed purchases were made mainly for wheelchair and accessories, clothing, haircut, snacks and so on. The Department added up the receipts to arrive at P&I purchases supported. A variance of $323.22 was noted between total P&I received and spent (supported by purchase receipts). It should be refunded to R2.


Cont'd on LIC 809C
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: GISELLE'S CARE HOME #2
FACILITY NUMBER: 041373048
VISIT DATE: 06/24/2022
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Finding 6): Accountability of Licensee Governing Body

All the findings noted indicate the licensee failed to exercise general supervision over
the affairs of the licensed facility. In addition to the above findings, several complaints
alleging S1 was abusive were filed after S1's departure. The complaints involved
multiple residents and for over a year period of time that the residents were afraid of
retaliation from S1 and did not say anything prior. Though some of the complaints
were still under RO investigation, these complaints indicate the licensee of the facility
failed to oversee the facility operation, which created the opportunity and atmosphere
for S1 to be abusive to the residents and take over $49,000 from R1’s family during a
2 year period without notice.

The following deficiencies were cited per Title 22 of the California Code of Regulation (See LIC 809D). Appeal Rights were explained and provided to the facility representative listed above and an Exit Interview was conducted. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 06/24/2022 12:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: GISELLE'S CARE HOME #2
FACILITY NUMBER: 041373048

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/25/2022
Section Cited

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87205, Accountability of Licensee Governing Body states-(a) The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves.
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This requirement is not met as evidenced by: Based upon documents reviewed and interviews the Licensee failed to oversee the facility operation, which created the opportunity for S1 to be abusive to the residents and take over $49,000 from R1’s family during a 2 year period. This poses an immediate Health, Safety risk to clients in care.
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Type B
08/05/2022
Section Cited

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87217(b). Safeguards for Resident Cash, Personal Property, and Valuables-facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources
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This requirement is not met as evidenced by: Based upon documents reviewed and interviews the Licensee failed to comply with cash handling requirements some P&I purchases were not supported by receipts.

This poses a potential risk to residents 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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 06/24/2022 12:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: GISELLE'S CARE HOME #2
FACILITY NUMBER: 041373048

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/25/2022
Section Cited

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87216 Bonding -(a) Each licensee, other than a county, who is entrusted to safeguard resident cash resources, shall file or have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal.
This requirement is not met as evidenced
by: Based upon document review and
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and interview. the Licensee failed to have a surety bond as required.

This poses a potential Health, Safety and/or Personal Rights risk to clients in care
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Type B
08/05/2022
Section Cited

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87507(g)(5)(C)1 Admission Agreements- Shall specify the following: refund condition: The licensee shall refund any prepaid monthly fees to a resident or the resident’s representative, if any, as follows:If a licensee forfeits the license upon the sale or transfer of the facility resulting in the resident’s transfer, as specified in 1569.682(a) H&S
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This requirement is not met as evidenced
by: Based upon document review and interview. the Licensee failed to refund R1’s responsible party

This poses a potential Health, Safety and/or Personal Rights risk to clients 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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022
LIC809 (FAS) - (06/04)
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