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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 097003566
Report Date: 05/19/2023
Date Signed: 05/19/2023 01:48:34 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/18/2023 and conducted by Evaluator Lavinia Muscan
COMPLAINT CONTROL NUMBER: 59-AS-20230518124345
FACILITY NAME:LAKE VIEW RESIDENTIAL CAREFACILITY NUMBER:
097003566
ADMINISTRATOR:PASHINA, ELENAFACILITY TYPE:
740
ADDRESS:2932 ABERDEEN LANETELEPHONE:
(916) 933-1230
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY:6CENSUS: 5DATE:
05/19/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Alex LutsukTIME COMPLETED:
02:05 PM
ALLEGATION(S):
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Facility did not provide refund in a timely manner.
INVESTIGATION FINDINGS:
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On 5/19/23, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to open and deliver complaint findings into the allegations listed above and met with Administrator Alex Lutsuk.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

**Report continued on 9099-C**
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
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 59-AS-20230518124345
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: LAKE VIEW RESIDENTIAL CARE
FACILITY NUMBER: 097003566
VISIT DATE: 05/19/2023
NARRATIVE
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Administrator acknowledged not paying refund to the family/responsible party of R1 who was deceased on 01/2/23. Based on regulation requirements (87507(g)(5)(A)(1) Admission Agreements), facility should have paid refund to R1's responsible party within 15 days after R1's death. As of May 19, 2023 the responsible party did not receive the refund of $5870.99. During today's visit, administrator stated payment was issued to R1's responsible party today May 19, 2023.
Based on Title 22 regulations, licensee did not issue a refund to R1's responsible party within 15 days therefore, LPA finds that the allegation cited above is Substantiated. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The deficiencies are cited on 9099-D, per Title 22 Regulations, Division 6.

Exit interview with administrator. Appeals rights provided. Copy of the report provided to facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20230518124345
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: LAKE VIEW RESIDENTIAL CARE
FACILITY NUMBER: 097003566
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/01/2023
Section Cited
CCR
87507(g)(5)(A)(1)
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87507(g)(5)(A)(1)- Admission Agreements(g) Admission agreements shall specify the following:
(5) Refund conditions(A) Facility policy concerning refunds, ...conditions under which a refund for ... fees will be returned in the event of a resident’s death, pursuant to Health and Safety Code section 1569.652… must be made to the individual...for the payment of the resident’s fees,... identified in admission agreement. 1569.652(c) A refund …
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Licensee agrees to submit a statement of understanding of this regulation and proof of payment of refund ($5870.99) to CCL by the POC date- 6/01/23.
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within 15 days after the personal property is removed. This requirement was not as evidence by- facility did not pay the refund to R1s family/responsible party within 15 days of R1s death as required per 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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC9099 (FAS) - (06/04)
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