198601959-3-17-2022-28-AS-LHIS-CDDPTF-20220411113550

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601959
Report Date: 03/17/2022
Date Signed: 03/17/2022 05:25:48 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, 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
06/21/2021 and conducted by Evaluator Angelica Rea

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210621085853

FACILITY NAME:	MOM & DAD'S HOUSE		FACILITY NUMBER:	198601959
ADMINISTRATOR:	IVONNE A. MEADER		FACILITY TYPE:	740
ADDRESS:	4340 CONQUISTA AVE.		TELEPHONE:	(562) 627-0390
CITY:	LAKEWOOD	STATE: CA	ZIP CODE:	90713
CAPACITY:	6	CENSUS: 6	DATE:	03/17/2022
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Ivonne Meador		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Illegal Eviction
Facility is not following admission agreement

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angelica Rea conducted another visit to deliver the final results of the investigation. LPA met with Staff, Celia Silva who allowed entry into the facility, and assisted with today's visit. Ms. Silva called Administrator, Ivonne Meador who arrived at the facility a short time later.

Regarding the allegation that Resident #1 was illegally evicted, the investigation consisted of interview with Administrator, Interview with Resident #1's family member, and review of Resident #1's file. The investigation revealed that Resident #1 was admitted to the facility on 5/29/21. On 6/19/21, resident #1 was sent to the hospital to be evaluated.

Admnistrator denied that Resident #1 was evicted from the facility. Administrator stated that Resident #1 was sent to the hospital to be evaluated, and have her medications reviewed. However, when resident #1 was ready to be discharged from the hospital on 6/20/21, administrator stated that resident #1 could not return to the facility. Administrator provided LPA with copy of text message sent to hospital CEO stating that "Resident #1 needs a Geri psych, and facility can’t take her back under the current condition".

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2022

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 28-AS-20210621085853

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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MOM & DAD'S HOUSE	FACILITY NUMBER: 198601959
	VISIT DATE: 03/17/2022

NARRATIVE

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Regarding the allegation that the facility is not following the admission agreement, the investigation consisted of interview with Administrator, Interview with Resident #1's family member, and review of Resident #1's file. LPA reviewed resident #1's admission agreement and observed that the facility charged resident #1 a $2500 processing fee. LPA also obtained copy of invoice dated 5/26/21 in the amount of $2500. LPA reviewed the approved admission agreement in the facility file, and observed that the approved facility admission agreement did not include a "processing fee". Administrator stated that she charges a processing fee" at her other facility. LPA explained that the facility must get approval before making changes to the approved admission agreement. Administrator stated that she has provided resident #1's family with a refund for the amount of the preadmission fee of $2500..

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code.

An exit interview was conducted with Ms. Meador. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20210621085853

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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MOM & DAD'S HOUSE	FACILITY NUMBER: 198601959
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/17/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/18/2022 Section Cited CCR 87224	1 2 3 4 5 6 7	Eviction Procedures. The licensee may, upon thirty (30) days written notice to the resident, evict the resident for nonpayment of the rate for basic services, failure to comply with state or local law, failure to comply with the general policies of the facility, development of a need not previously identified, and/or a change of use of the facility.	1 2 3 4 5 6 7	Administrator shall abide by Title 22 regulations, 87224 Eviction Procedures. Administrator will review section 87224, and will provide LPA with a written statement, stating she has reviewed and understands the regulation.
	8 9 10 11 12 13 14	This requirement is not being met as evidenced by: Administrator did not allow resident #1 to return to the facility when she was being discharged from the facility on 6/20/21.	8 9 10 11 12 13 14
Type A 03/18/2022 Section Cited HSC 1569.651(d)	1 2 3 4 5 6 7	(d) Any fee charged by a licensee of a residential care facility for the elderly, whether prior to or after admission, shall be clearly specified in the admission agreement.	1 2 3 4 5 6 7
	8 9 10 11 12 13 14	This requirement is not being met as evidenced by: LPA obseved that approved admission agreement has been altered, and resident #1 was charged a $2500 processing fee on admission agreement dated 5/29/21.	8 9 10 11 12 13 14	Administrator will review health and safety code 1569.651 and will provide LPA with a written statement stating she has reviewed and understands the regulation. Administrator stated she sent revised admission agreement including preadmission fee to LPA Mora on 6/23/21.

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2022

LIC9099 (FAS) - (06/04)

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