079201090-3-23-2023-15-AS-YFLS-CSYQ7S-20230620115538

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201090
Report Date: 03/23/2023
Date Signed: 03/23/2023 03:47:22 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
02/10/2023 and conducted by Evaluator Lizette Francisco

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230210092132

FACILITY NAME:	A SPRINGTIME RESIDENCE		FACILITY NUMBER:	079201090
ADMINISTRATOR:	TRUCKS, CHRISTINA		FACILITY TYPE:	740
ADDRESS:	2752 MOHAWK CR.		TELEPHONE:	(415) 290-7611
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	6	CENSUS: 6	DATE:	03/23/2023
		UNANNOUNCED	TIME BEGAN:	02:55 PM
MET WITH:	Isagani Silvestre, Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Licensee did not refund responsible party in a timely manner after resident's death

INVESTIGATION FINDINGS:

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On 3/23/2023 starting at 2:55 PM, Licensing Program Analyst (LPA) L. Francisco and K. Nguyen arrived unannounced to deliver findings for the above allegation. LPAs met with Administrator Isagani Silvestre and explained the purpose of the visit.

During the course of the investigation, LPA L. Francisco reviewed records, obtained information and interviewed staff. It is alleged licensee did not refund responsible party in a timely manner after resident's death. Based on record review and interview, R1 passed away on 1/5/2023 and belongings were removed on 1/10/2023. Interview with S1 revealed that a check was not issued to R1's responsible party within 15 days of items being removed from facility. LPA discovered that S1 dropped off a post dated check to F1 on 2/8/2023. However, on 3/7/2023, LPA L. Francisco discovered that F1 was unable to cash the check issued by the facility due to no funds.

REPORT CONTINUES ON 9099

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

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-20230210092132

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 SPRINGTIME RESIDENCE	FACILITY NUMBER: 079201090
	VISIT DATE: 03/23/2023

NARRATIVE

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Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted with Administrator and Licensee over the phone. Appeal rights and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20230210092132

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 SPRINGTIME RESIDENCE	FACILITY NUMBER: 079201090
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/23/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/24/2023 Section Cited CCR 1569.652(c)	1 2 3 4 5 6 7	1569.652 Termination of admission agreement upon death of resident (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,...within 15 days after the personal property is removed.	1 2 3 4 5 6 7	By POC date, Administrator will issue a cashier's check of $11,032.30
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interview and record review, Licensee did not comply with section cited above by not issuing R1's responsible party a refund of $11,032.30 with 15 days which poses an immediate personal rights to persons in care.	8 9 10 11 12 13 14
	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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

LIC9099 (FAS) - (06/04)

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