075601425-10-29-2020-15-AS-KHOS-BVAPR9-20201112103222

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601425
Report Date: 10/29/2020
Date Signed: 10/29/2020 12:45:31 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
03/05/2020 and conducted by Evaluator Rolanda Pitcher

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20200305114153

FACILITY NAME:	CRUSE HOUSE ALOHA		FACILITY NUMBER:	075601425
ADMINISTRATOR:	REYES, VIRGIL T.		FACILITY TYPE:	740
ADDRESS:	1850 MARINA COURT		TELEPHONE:	(925) 356-2256
CITY:	CONCORD	STATE: CA	ZIP CODE:	94520
CAPACITY:	6	CENSUS: 6	DATE:	10/29/2020
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Virgil Reyes		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility did not issue proper refund.

INVESTIGATION FINDINGS:

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Licensing Program Analyst, (LPA) Rolanda Pitcher conducted an investigation regarding "facility did not issue proper refund." During the course of this investigation, LPA met with Administrator, Virgil Reyes for this purpose.

Based on interviews conducted with all pertinent parties. LPA learned the resident (R1) moved into the facility on 1/18/20, and passed away on 1/20/20. The Administrator and R1's responsible party agree the 1st month payment of $4,000 was recieved on 1/18/20. All parties agree the resident personal property was removed from the facility within 15 days. LPA also obtained a copy of R1's death certificate and check in the amount of $4,000. LPA has determined a refund in the amount of $3,734 is due per Health and Safety (H/S) 1569.652 Regulation @ $133.00 a day.

Report continued on LIC 9099C

Substantiated

Estimated Days of Completion: 30

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Rolanda Pitcher	TELEPHONE: (510) 542-0253
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2020

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-20200305114153

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: CRUSE HOUSE ALOHA	FACILITY NUMBER: 075601425
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/29/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/31/2020 Section Cited HSC 1569.652	1 2 3 4 5 6 7	Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination 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, or entity contractually responsible for the fees or, if the	1 2 3 4 5 6 7	Licensee agrees a refund in the amount of $3,734 is due to the R1's responsibe party.
	8 9 10 11 12 13 14	deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed. This requirement is not met as evidenced by licensee's failure to issue a refund to R1's responsible party for fees paid in advance. R1 resided in facility for approximately 2 days. R1's belongings were removed from the facility within 15 days.	8 9 10 11 12 13 14	Administrator stated a refund for fees paid in advance will be issued to R1's responsible party by POC date.
	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: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Rolanda Pitcher	TELEPHONE: (510) 542-0253
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20200305114153

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: CRUSE HOUSE ALOHA	FACILITY NUMBER: 075601425
	VISIT DATE: 10/29/2020

NARRATIVE

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Licensee provided LPA a copy of R1's death certificate and check in the amount of $4,000.

The Department has completed this investigation and determined the complaint is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of evidence of standard has been met.

Deficiency cited under Title 22, Division 6. See LIC 9099D.

Due to the present shelter in place order by the Governor, this report was delivered via email.

Appeal Rights Given

Exit interview conducted Virgil Reyes

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Rolanda Pitcher	TELEPHONE: (510) 542-0253
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2020

LIC9099 (FAS) - (06/04)

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