079200391-8-24-2020-15-AS-HHUL-BTRTLJ-20200924144939

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200391
Report Date: 08/21/2020
Date Signed: 08/24/2020 10:04:21 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
06/16/2020 and conducted by Evaluator Rolanda Pitcher

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20200616161927

FACILITY NAME:	FLORENCE SENIOR HOME		FACILITY NUMBER:	079200391
ADMINISTRATOR:	MARY MALEKAMU		FACILITY TYPE:	740
ADDRESS:	1841 FLORENCE LANE		TELEPHONE:	(925) 566-8062
CITY:	CONCORD	STATE: CA	ZIP CODE:	94520
CAPACITY:	6	CENSUS: 4	DATE:	08/21/2020
		UNANNOUNCED	TIME BEGAN:	02:40 PM
MET WITH:	Mary Malekamu		TIME COMPLETED:	05:10 PM

ALLEGATION(S):

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Facility operates under another name.

Facility was not maintained in a clean and orderly fashion.

Facility has pests.

Facility failed to issue responsible party a refund upon resident's death.

INVESTIGATION FINDINGS:

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On 8/14/20 at 2:40 pm, Licensing Program Analyst, (LPA) Rolanda Pitcher conducted a Tele-Visit with S1, S2 regarding the above allegations.

Due to the present shelter in place order by the Governor, this inspection was conducted via video-conference. During the course of the call LPA conducted 2 interviews, record review and a virtual tour of the facility.

LPA observed the facility was clean and organized. LPA observed no evidence of pest such as rodents (droppings), spiders (webs) or ants. LPA obtained a copy the admission agreement, (3/28/20) allegedly completed with the Administrator and R1's responsible party. LPA noted the name on the admission agreement provided by S1 states the license facility name is Florence Senior Home. The name on the refund reciept indicates another name which is the pending facility license name.

Report continued on LIC9099

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.

Exit interview was conducted with Administrator, Mary Malekamu

Unsubstantiated

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: 08/21/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2020

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-20200616161927

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: FLORENCE SENIOR HOME	FACILITY NUMBER: 079200391
	VISIT DATE: 08/21/2020

NARRATIVE

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The admission agreement states resident was admitted to Florence Senior Home was on 3/28/20. Total amount paid $6,750 in which $2,250 non-refundable community fee.

LPA learned the resident was admitted to hospital on 4/2/20 and personal property was removed from the facility on 4/8/20. Therefore amount owed and paid was for 11 days @ 150 = 1,500. Due to the inconsistency on whether the responsible party was provided a copy of the admission agreement stating $2,250 paid was non-refundable and proof that a refund in the amount of $3,300 was paid to the responsible party on 4/24/20.

LPA found no evidence to substantiate the remainder in refund should be $1,800 equaling a refund in the amount of $5,100.

The department has determined based upon records review and interviews conducted the above allegation is unsubstantiated. A finding that an allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Rolanda Pitcher	TELEPHONE: (510) 542-0253
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2020

LIC9099 (FAS) - (06/04)

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