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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201088
Report Date: 03/07/2023
Date Signed: 03/07/2023 11:05:29 AM

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
02/16/2023 and conducted by Evaluator James Sampair
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230216170240
FACILITY NAME:LAFAYETTE RESIDENTIAL CAREFACILITY NUMBER:
079201088
ADMINISTRATOR:OPHELIA PEDROSOFACILITY TYPE:
740
ADDRESS:1300 JUANITA DRIVETELEPHONE:
(925) 945-6833
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:6CENSUS: 4DATE:
03/07/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Telesha ClarkeTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility staff did not refund resident's authorized representative upon the death of the resident in a timely manner.
INVESTIGATION FINDINGS:
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At 9:00 AM on 03/07/2023, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to deliver findings for the above allegation. LPA met with Administrator (ADM) Consultant Telesha Clarke to explain the reason for the visit.

During the investigation, LPA interviewed Ms. Clarke who, after speaking with Licensee, was unable to supply records of a refund having been sent to complainant.

Based on the data collected over the course of the investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED.

Deficiencies are 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.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023
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-20230216170240
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: LAFAYETTE RESIDENTIAL CARE
FACILITY NUMBER: 079201088
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/14/2023
Section Cited
HSC
1569.652(c)
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1569.652 Termination of admission agreement upon death of resident; removal of resident’s property ... (c) A refund of any fees paid in advance ... shall be issued ... within 15 days after the personal property is removed.
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Licensee shall send proof of full refund sent to complainant on or before due date.
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This requirement was not met as evidenced by no evidence of having made a refund of R1's fees paid in advance of her death on 07/04/2022, which is in violation of Title 22 Section 87507 refund regulation.
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023
LIC9099 (FAS) - (06/04)
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