198601976-6-14-2021-28-AS-MVAO-C4FQFE-20210629120748

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601976
Report Date: 06/14/2021
Date Signed: 06/14/2021 02:57:09 PM

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
10/13/2020 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20201013091459

FACILITY NAME:	DEL MAR PARK		FACILITY NUMBER:	198601976
ADMINISTRATOR:	DENISE SUTTON		FACILITY TYPE:	740
ADDRESS:	990 EAST DEL MAR BOULEVARD		TELEPHONE:	(626) 577-0215
CITY:	PASADENA	STATE: CA	ZIP CODE:	91106
CAPACITY:	60	CENSUS: 44	DATE:	06/14/2021
		UNANNOUNCED	TIME BEGAN:	11:56 AM
MET WITH:	Denise Sutton - Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff did not issue a refund.

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s) Mary Flores conducted a complaint investigation visit for the above allegation. LPA met with Denise Sutton administrator and explained the reason for the visit.

The investigation consisted of the following: On 10/19/20 LPA Flores conducted telephone interviews with the administrator, and resident service coordinator. The LPA also requested copies of resident/staff roster, fee schedule, admissions agreements, financial documents, physician's report, medication sheets, notes, and service and care plan for resident #1, resident #2, resident #3 (R1, R2, R3) to be emailed to the LPA by 10/20/20. On 6/14/21 LPA met with Denise Sutton administrator and requested to review R1 personal file, requested copies of financial statements for the months of January, February, and March 2020 for R1, checks payable to R1's responsible party, Admission agreement, physician's report for R1, and resident roster for January and February,
The investigation revealed the following: Regarding allegation: Staff did not issue a refund. It is alleged; R1 had to move out because he needed extra care that the facility could not provide. Administrator gave R1's responsible party a 30-day written notice. (CONTINUED LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

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 28-AS-20201013091459

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: DEL MAR PARK	FACILITY NUMBER: 198601976
	VISIT DATE: 06/14/2021

NARRATIVE

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Administrator stated to owe R1's responsible party $2907.50 in total, and subtracting $387.50 which had been reimbursed on early March, Facility still owed responsible party $2520.00. On 10/19/20 LPA Flores interview R1's responsible party who stated administrator had said to owe R1's responsible party $2907.50 and two checks have been issued 1) on 3/9/20 for the amount of 2168.72 and 2) on the second week of April for the amount of 387.50 During R1's file review, LPA observed the following; R1 was admitted to the facility on 9/1/18, R1 was taken to the hospital on 1/27/20, from hospital R1 went to nursing home on 2/4/20 facility provided a 30 day notice at the end of January per R1's representative. R1's last physical day at the facility was 1/27/20 and last day of board and room was on 2/27/20. LPA reviewed a facility's letterhead letter dated 3/24/20 with breakdown charges for January and February 2020 as follow; January 2020 Charges for room and board and other services total $5080; Payments $5080 balance $0. February 2020 Charges for room and board (26 days) no charges for other services total $2172.50 Payments $5080 Balance $2907.50. Letter states Facility owes R1's responsible party $2907.50 deducts $387.50 paid on 3/20/21 leaving a balance of $2520.00 owed to R1's responsible party. LPA was provided with a copy of second check issued to R1's responsible party on 4/1/21 for the amount of $2168.27 leaving a balance owe to R1's responsible party of $351.73. Interview with facility's administrator revealed facility has issued two checks to R1's responsible party 1) dated on 3/9/20 for the amount of $387.50 posted bank on 4/9/20 and 2) dated 4/1/20 for the amount of $2168.27 posted bank on 4/9/20. Therefore facility owes R1's responsible party the amount of $351.73.

Based on file review and interviews, conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 are being cited in the attached LIC 9099D.

Exit interview was conducted with Denise Sutton and a copy of report, LIC 9099D, and appeal rights was provided.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20201013091459

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: DEL MAR PARK	FACILITY NUMBER: 198601976
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/28/2021 Section Cited CCR 87507(g)(5)(c)	1 2 3 4 5 6 7	87507 Admission Agreements: (g)... shall ..: (5) Refund conditions. (c) A refund of any fees paid in advance...after the resident’s personal property has been removed...shall be issued ... if ... resident paid the fees, ... within 15 days after the personal property is removed. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Administrator will issue R1's responsible party a check for the amount of $351.73 and will submit proof of reimbursment to the department by 6/28/21.
	8 9 10 11 12 13 14	Based on file review and interview facility did not issue total refund amount to R1's responsible party. Total amount to reimburse was $2907.50 amount reimbursed and posted on 4/20/20 $2555.77. A total of $351.73 owe to R1's responsible party which poses a potential Health, Safety, or Personal Rights risk to persons in care.	8 9 10 11 12 13 14
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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: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

LIC9099 (FAS) - (06/04)

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