198602067-3-19-2021-28-AS-MVAO-C5KLBS-20210804083713

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602067
Report Date: 03/02/2021
Date Signed: 03/19/2021 11:12:49 AM

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
01/07/2021 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210107085253

FACILITY NAME:	HOUSE OF GRACE LLC		FACILITY NUMBER:	198602067
ADMINISTRATOR:	MICHELLE AGUIRRE		FACILITY TYPE:	740
ADDRESS:	618 RIDGEFIELD DRIVE		TELEPHONE:	(626) 716-1033
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	6	CENSUS: 4	DATE:	03/02/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Michelle Aguirre		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Licensee did not issue a refund in a timely manner

INVESTIGATION FINDINGS:

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The purpose of this report is to deliver the findings from the original complaint dated 1/7/21.
On initial visit 1/14/21 the following occurred:
Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, investigation was conducted telephonically with Michelle Aguirre, Administrator.
Copy of staff roster and resident roster to be submitted. Facility to also submit Resident 1's Emergency ID Page, Physician's Report and Admissions Agreement.
The investigation for allegation Licensee did not issue a refund in a timely manner consisted of the following:
Telephonic interviews with Administrator and Family Member of Resident 1 (POA and Authorized Representative), Copies of refund checks, review of e-mail documentation, and review of Admission Agreement, Physician's Report and Personal Rights documents for Resident 1.
In regards to the allegation Licensee did not issue a refund in a timely manner, based on interviews conducted and information gathered it was revealed that Resident 1 had passed away on 5/5/20 with rent being paid for the whole month for 4,000.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2021

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-20210107085253

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: HOUSE OF GRACE LLC	FACILITY NUMBER: 198602067
	VISIT DATE: 03/02/2021

NARRATIVE

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Refund checks show payments totaling $2596.72 given to Resident 1's authorized representative from the facility. May 1 to May 5 to reside in the facility cost $645.15. Leaving the amount due to Resident 1's authorized representative as $758.13.
Administrator stated that the remaining balance will be withheld because damage to the carpet caused by Resident 1's behavior of peeing and removing diapers and throwing them on the carpet and damaging walls with pee and bowel movement.
Resident 1's authorized rep confirmed that facility did not want to give refund based on facility saying carpet and walls were damaged.
It should be noted that Resident 1's Admission date was 4/15/20 and Admission Agreement was signed by authorized representative for Resident 1 and states that we shall not require, request or accept any funds from a resident or resident's representative that constitutes as a deposit against any possible damages by a resident.
Administrator also stated in the interview that they now have a new Admissions Agreement which includes Breakages/damage fees.
Interviews and information gathered revealed that there were no changes made to the original Admissions Agreement related to any fees to be charged and that the new Admissions Agreement had not been signed and was discussed after the passing of Resident 1 on May 5th.

Based on LPA’s observations and interviews which were conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D.

Report e-mailed to facility for signature.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210107085253

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: HOUSE OF GRACE LLC	FACILITY NUMBER: 198602067
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/02/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/10/2021 Section Cited HSC 1569.651(d)	1 2 3 4 5 6 7	Preadmission fee or deposit for elderly at residential care facilities 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. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator to submit proof of payment back to authorized representative for Resident 1 by POC due date.
	8 9 10 11 12 13 14	Based on interviews conducted and information gathered the licensee failed to ensure that any fee to be charged prior to or after admission be clearly specified in the Admissions Agreement when charging Authorized Representative for Resident 1 for damages after resident passed away. This posed an Immediate Health, Safety or Personal Rights risk to residents in care.	8 9 10 11 12 13 14
	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: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2021

LIC9099 (FAS) - (06/04)

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