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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075600577
Report Date: 09/25/2024
Date Signed: 09/25/2024 02:34:28 PM

Unsubstantiated


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
09/23/2024 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240923111808
FACILITY NAME:MORAGA ROYALEFACILITY NUMBER:
075600577
ADMINISTRATOR:RICKMAN, FAILELOTO TFACILITY TYPE:
740
ADDRESS:1600 CANYON ROADTELEPHONE:
(925) 376-8900
CITY:MORAGASTATE: CAZIP CODE:
94556
CAPACITY:120CENSUS: 82DATE:
09/25/2024
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Faileloto RickmanTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Staff unlawfully evicted resident.
INVESTIGATION FINDINGS:
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On this day at around 10:25 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct investigation on the above allegation. LPA met with Faileloto Rickman, Executive Director (ED). LPA explained to Rickman the purpose of the visit.

During the visit, LPA obtained and reviewed the following records of R1: Lic 501, Physician's Report, notice to vacate and copies of power of attorney (POA). LPA interviewed Rickman and Licensee Jonathan Berg.

Based on interviews conducted, Rickman and Berg both denied evicting R1. Both state that R1's son(W2)/ POA sent an email to the facility on 9/9/2024 stating that R1 "will not be returning to Moraga Royale..."
And that the facility can arrange with R1's other son, W1 to have R1's belongings collected.

continuation on Lic 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
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 2
Control Number 15-AS-20240923111808
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: MORAGA ROYALE
FACILITY NUMBER: 075600577
VISIT DATE: 09/25/2024
NARRATIVE
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LPA reviewed the email notice to vacate sent to the facility by R1's son (W2)/POA. The email confirmed that R1's POA issued a written notice to the facility that R1 is moving out of the facility.

LPA reviewed five different POAs and obtained the following information:
  • On 3/3/2024, W1 was designated as R1's POA
  • On 4/24/2024, W2 was designated as R1's POA
  • On 8/28/2024, W2's designation as POA was revoked; no POA was designated
  • On 9/3/2024, W2 was designated as R1's POA
  • On 9/13/2024, W2's designation as POA was revoked


R1 was officially discharged from the facility on 9/9/2024.

Based on record reviews and interviews conducted, the above allegation is unsubstantiated.

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.

There is no deficiency noted for this visit.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2