197606472-8-11-2023-28-AS-TVAO-CUZKUC-20230824081227

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606472
Report Date: 08/11/2023
Date Signed: 08/11/2023 12:15:09 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/04/2023 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230804154800

FACILITY NAME:	BANNER RIDGE COUNTRY HOME		FACILITY NUMBER:	197606472
ADMINISTRATOR:	ELNA C. VILLAFLOR		FACILITY TYPE:	740
ADDRESS:	1006 BANNER RIDGE ROAD		TELEPHONE:	(909) 240-1899
CITY:	DIAMOND BAR	STATE: CA	ZIP CODE:	91765
CAPACITY:	6	CENSUS: 6	DATE:	08/11/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Zenaida Uy, Assistant Administrator		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Facility will not provide refund to responsible party.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation for the allegation listed above. LPA arrived unannounced and met with Zenaida Uy, the Assistant Administrator. Administrator, Elna Villaflor, could not attend in person, therefore, the purpose for the visit was provided over the phone.

The investigation consisted of the following:
LPA obtained a copy of the staff roster, resident roster, and documents pertaining to Resident #1 (R-1). Interviews were conducted with the Administrator and Assistant Administrator.

The investigation revealed the following:
Allegation - Facility will not provide refund to responsible party. It is alleged that Resident #1’s (R-1) family requested for a refund of the fees paid in August 2023 and the administrator refused to provide the refund.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

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 28-AS-20230804154800

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BANNER RIDGE COUNTRY HOME	FACILITY NUMBER: 197606472
	VISIT DATE: 08/11/2023

NARRATIVE

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Per the administrator, R-1’s family member requested to prorate the rent amount for August but could not provide the exact date when R-1 will move out. Therefore, the family paid the entire month of August and moved out on 8/5/23. The Administrator informed the family that she will prepare the refund and have it sent to them by 8/20/23. Based on documentation, R-1’s discharged paperwork indicated the departure date of 8/5/23. The administrator created the credit memo dated 8/7/23 with the amount charged, paid, and balance credit. The administrator stated the refund check was mailed out to the responsible party on 8/10/23. Based on interviews and record review, the facility provided a refund check to the responsible party within 15 days after the personal property was removed.

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.

An exit interview was conducted with Assistant Administrator. A copy of this report along with the appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC9099 (FAS) - (06/04)

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