197608280-8-18-2021-29-AS-JAPL-C5ZR27-20210818123748

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608280
Report Date: 07/20/2021
Date Signed: 08/18/2021 12:35:29 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/16/2021 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20210716131848

FACILITY NAME:	FOUR SEASONS ASSISTED LIVING CENTER LLC		FACILITY NUMBER:	197608280
ADMINISTRATOR:	MELISSA CHRISTOPHER		FACILITY TYPE:	740
ADDRESS:	12120 CHANDLER BLVD		TELEPHONE:	(818) 487-0770
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91607
CAPACITY:	49	CENSUS: 28	DATE:	07/20/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Melissa Christopher		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not provide written notice to the resident for rate increase.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

This is an amended report for the report report issued on 07/20/2021. On 7/20/2021, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced initial complaint investigation regarding the above allegation. LPA met with the Administrator at 1:00pm and explained the reason for the visit. LPA also spoke to the complainant on the same date.
Interviews:
LPA interviewed Resident 1(R1) about allegation of increased rent fee, and failure from licensee to inform R1 about the rent increase. R1 provided a copy of the letter given by administrator on May 14, 2021 to R1 about the increase in rental fee. The letter is a copy of a Provider Information Notice (PIN) 20-26-CCLD: ESTIMATED SSI/SSP PAYMENT STANDARDS EFFECTIVE JANUARY 1, 2021. The PIN is dated 11/01/2020. The PIN is sent to all Licensees. Additionally, R1 provided LPA with a copy of the Payment Reconciliation Summary which was received by R1 from Business Office Manager on 07/16/2021, which indicates that the rent increase, started on 01/01/2021.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021

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 29-AS-20210716131848

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FOUR SEASONS ASSISTED LIVING CENTER LLC	FACILITY NUMBER: 197608280
	VISIT DATE: 07/20/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

At 2:20pm, LPA interviewed Administrator about the date of notification given to residents in relation to the rent increase for SSI Recipients. Administrator stated that a PIN was received from Business Office Manager on May 13, 2021, which was to be given to SSI recipient residents. Letter (PIN) was given to residents on May 14, 2021.

Records Review:

During the record review, at 3:00pm LPA read Admission Agreement found in complainant’s file. Per the agreement, page 4, under Notice of Rate Changes: If the rate change reflects a government fund increase, written notice is required from the licensee as soon as FOUR SEASONS ASSISTED LIVING is notified. Four Seasons Assisted Living received PIN notice of increased funds on 11/02/2020.

The facility did not provide a notice to residents of the rent increase as stated in the admission agreement. Residents received an increase rent fee letter on 05/14/2021.

Based on the investigation, there is sufficient evidence to support the claim that the Facility did not provide written notice to the resident for rate increase as stated in the Admission Agreement.

Therefore, this allegation is deemed Substantiated at this time.

Exit interview Conducted. Deficiencies cited, and a copy of report and appeal rights given to Administrator.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20210716131848

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FOUR SEASONS ASSISTED LIVING CENTER LLC	FACILITY NUMBER: 197608280
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/20/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/27/2021 Section Cited CCR 87567(c)(4)	1 2 3 4 5 6 7	ADMISSION AGREEMENTS: Licensee’s failure to provided written notice to resident as stated in admission agreement. New rent increase became effective 01/01/2021. Resident was charged new rent increase as 01/01/2021. Resident received written notice on 05/14/2021.	1 2 3 4 5 6 7	Licensee will create a formal Notice of Rate Increase letter to be used to provide residents with a written notice as stated in the Admission Agreement. Letter is due to LPA by 7/27/2021.
	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
	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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3