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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200881
Report Date: 04/07/2022
Date Signed: 04/07/2022 12:34:57 PM

Substantiated


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
04/05/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220405160059
FACILITY NAME:A BLISSFUL RETREAT, LLC-WILSONFACILITY NUMBER:
079200881
ADMINISTRATOR:OSMAN, SUMAIYAFACILITY TYPE:
740
ADDRESS:4248 WILSON LANETELEPHONE:
(925) 375-1581
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 2DATE:
04/07/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Sumaiya Osso, Licensee
Jenny Urquiaga, Administrator		TIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Facility over charged resident
INVESTIGATION FINDINGS:
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On 04/07/22 at 11AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced complaint visit, met with administrator, gathered information and delivered investigation finding to administrator. LPA explained the purpose of the visit with licensee on the phone who authorized the administrator to act on her behalf and sign the reports.

During investigation, LPA reviewed copies of resident's (R1) signed admission agreement dated 11/11/21 and billiing invoices dated 11/13/2021 and 11/29/21. The invoice dated 11/13/21 showed an item charge of $1000 described as "emergency move in same day move". The other invoice dated 11/29/21 for December billing showed an item charge of $50 for Gloves. Both these charges were unauthorized and not included in R1's signed admission agreement dated 11/11/21.

Continued on next page, LIC 9099-C

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
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-20220405160059
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: A BLISSFUL RETREAT, LLC-WILSON
FACILITY NUMBER: 079200881
VISIT DATE: 04/07/2022
NARRATIVE
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Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) was found to be substantiated.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20220405160059
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: A BLISSFUL RETREAT, LLC-WILSON
FACILITY NUMBER: 079200881
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/22/2022
Section Cited
CCR
87507(g)(3)(B)
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Admission agreements shall specify the following: (g)(3)(B) A separate charge for an item or service may be assessed only if that charge is included in and authorized by the admission agreement.
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Licensee agreed to comply with Title 22 Section 87507 regulation during visit. Licensee agreed to issue a total refund of $1,050 to resident's (R1) authorized representative on or before POC due date of 04/22/22.
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This requirement was not met as evidenced by unauthorized surcharge total of $1,050 billed to resident which were not included in the signed admission agreement.
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Licensee agreed to submit a copy of refund check of $1,050 on or before POC due date to LPA via email.

Failure to comply with this requirement may result in civil penalties.
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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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3