198201753-3-3-2022-11-AS-MVAO-CE3NZP-20220503105439

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201753
Report Date: 03/03/2022
Date Signed: 03/03/2022 03:07:14 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/25/2022 and conducted by Evaluator Jade Jordan

COMPLAINT CONTROL NUMBER: 11-AS-20220225151411

FACILITY NAME:	EMERALD ISLE ASSISTED LIVING #2		FACILITY NUMBER:	198201753
ADMINISTRATOR:	MARTZ, LAURA DAWN		FACILITY TYPE:	740
ADDRESS:	28016 CALZADA DR.		TELEPHONE:	(310) 351-7075
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90274
CAPACITY:	6	CENSUS: 3	DATE:	03/03/2022
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Laura Martz		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility did not issue refund to resident's authorized representative

INVESTIGATION FINDINGS:

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On 03/03/22 Licensing Program Analyst (LPA) Jade Jordan conducted an unannounced complaint investigation regarding the allegation above. LPA was greeted by staff Joy, spoke with the Administrator Laura telephonically. The purpose of the visit was explained.

Investigation Consisted of: Physical Plant tour, Interview with Administrator, Resident interviews, Record Review of Text messages, Admissions Agreement, Physicians Report, Pre-Appraisal, and Physical Plant Tour.

Regarding Allegation: Facility did not issue refund to resident's authorized representative
Rp stated the Resident (R1) was brought to facility to reside there on 01/18/22. On the same day, several hours later R1 was sent from facility, to the hospital. R1 was admitted to the hospital for several days, and it was decided later, that R1 would not return back to the facility. RP stated that they were told by Administrator, that a refund check was being issued, but has not yet been received. RP stated that they were told by the Administrator that the mailed check had been returned. Rp told LPA To date, no check has been received.
********** Continued on 9099C**********************

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

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 11-AS-20220225151411

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: EMERALD ISLE ASSISTED LIVING #2	FACILITY NUMBER: 198201753
	VISIT DATE: 03/03/2022

NARRATIVE

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Interviews with Administrator revealed the room for R1 was held from 01/18/22, until 02/06/22 in which it was informed by the family member, that R1 would not be returning back to facility. A prorated amount of $3450.00 was issued by check, dated 02/09/22 and mailed to the address listed of the Power of Attorney (POA) on 02/10/22.

Administrator provided LPA with copies of text messages. LPA observed Text messages between Administrator and Family Member in which the Administrator provided a screens shot of the check, and Invoice as proof of attempted mailed check.

LPA compared the address in which the check was mailed, to the address listed for POA, check was mailed as it was listed. LPA observed in text message screen shot, an envelope addressed to the POA with a yellow label dated 02/17/22 indicating “Return to Sender No Such Number, Unavailable to Forward.” Administrator stated that they use a Po box which is listed as the sender and did not see that the check was returned until 02/23/22.

Observation of Text messages between Administrator and family member were observed of Administrator asking the family member for a correct address to re issue the check. Administrator stated that they have not received a response from R1’s POA, or Family member for use of a correct address. Administrator stated they are not intentionally trying to withhold refund.

Based on LPA Interviews, Record Review, and Observation the Department finds that “Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.”

An exit interview conducted, and a copy of this report provided.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

LIC9099 (FAS) - (06/04)

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