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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602099
Report Date: 04/02/2021
Date Signed: 07/31/2023 10:57:56 AM


Document Has Been Signed on 07/31/2023 10:57 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:CORAL OAKS CARE LIVINGFACILITY NUMBER:
198602099
ADMINISTRATOR:ELEANOR BARRIENTOSFACILITY TYPE:
740
ADDRESS:4271 CARLIN AVETELEPHONE:
(310) 763-4881
CITY:LYNWOODSTATE: CAZIP CODE:
90262
CAPACITY:84CENSUS: DATE:
04/02/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Sona BhatiaTIME COMPLETED:
10:05 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ulysses Coronel initiated a Case Management - Deficiencies Visit, to document deficiencies observed during investigation of complaint; 11-AS-20200506121602. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Sona Bhatia the licensee.

On 03/05/2021 LPA Coronel reviewed the Trust Audit of Coral Oaks Care Living submitted by Auditor Jessica Chen of the departments Audit Section and observed the following:

The bank statements reviewed by the auditor indicates that the facility kept the residents’ P&I in a business checking account titled Coral Oaks Care Living Inc., the account title, does not meet the requirements as it’s not reflect that the account holds residents’ money.

The facility provided a summary listing the residents’ money that is being safeguarded and the total amount. The total does not match to the bank statement total. The documentation provided and the delayed response from the facility indicate the facility failed to reconcile the records, or it was not done properly or timely.

The (AA) Admission Agreements indicates that the facility doesn’t accept SSI/SSP funding residents, which is contradictory to the fact that majority of the facility’s residents are SSI recipients. The statement "The facility does not accept SSI/SSP-dependent residents..." is stated on page 8 under Funding Source.

The AA's reviewed by the department do not indicate the payor and funding sources. Funding Sources questionnaires on pages 7 and 8 of the AA are left blank.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CORAL OAKS CARE LIVING
FACILITY NUMBER: 198602099
VISIT DATE: 04/02/2021
NARRATIVE
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The facility automatically added $20 to the SSI established B&C rate and had residents sign on the AA .The AA payment provisions do not contain language that acknowledges if the residents / responsible party receives the additional exempt income of $20 from SSI or if the resident has the right and option to agree or reject paying the additional $20 for B&C / basic services.

All the deficiencies cited on Basic Services, Additional Personal Rights of Residents in Privately Operated Facilities, Safeguards for Resident Cash, and Admission Agreement indicate that the administrator failed to perform knowledge of and ability to conform to the applicable laws, rules and regulations.

An exit interview was conducted, appeals rights and a copy of this report was provided via email for review and signature.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/31/2023 10:57 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: CORAL OAKS CARE LIVING
FACILITY NUMBER: 198602099

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
05/03/2021
Section Cited
CCR
87217(g-h)

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87217(h) Safeguards for Resident Cash, Personal Property, and Valuables,Each licensee shall maintain adequate safeguards and accurate records of cash resources and valuables entrusted to his care....provided that the account title clearly notes that it is residents' money... licensee. This requirement was not met as evidenced by:
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The licensee will create a plan to correct the bank account title to reflect that it contains residents’ money.
The licensee will create a plan to periodically investigate and document variances noted on reconciliation of bank statements, residential financial ledgers, LIC 405.
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Based on record reviews. The licensee failed to ensure that the facility reconciles records and that residents cash resources were kept in an account with an account name clearly notes that it is holding residents' money, which poses a potential health and safety risk to residents in care.
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Plan of correction will be submited by POC due date.
Request Denied
Type B
05/03/2021
Section Cited
CCR87507(g)(3)(A).3&(F)

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87507(g)(3)(A).3&(F)Admission Agreement, Admission agreements shall specify the following: Payment provisions, including the following: Basic services rate(s), including: Exempt-income-allowance may be included if the resident agrees to such charge. Funding source, provided that the resident may refuse to disclose such source.
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The licensee will create a plan to correct the Funding Sources questionnaires on pages 7 and 8 of the residents Admission Agreements.

The licensee will create a plan to specify $20 Exempt-income-allowance charges and the residents option to agree with such charges on Admission Agreemnts.
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Based on record reviews the licencee failed to ensure that AAs specify Exempt-income-allowance charges and the residents option to agree with such charges and that Payment provisions specifies Funding Sources, which poses a potentia risk to residents in care.
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Plan of correction will be submited by POC due date.
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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 07/31/2023 10:57 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: CORAL OAKS CARE LIVING
FACILITY NUMBER: 198602099

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
04/22/2021
Section Cited
CCR
87405(d)(2)

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87405(d)(2) Administrator - Qualifications and Duties. The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all ...apply. Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by:
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The licensee will create a plan to ensure that the administrator performs knowledge of and conforms to applicable laws, rules and regulations. Plan of correction will be submited by POC due date.
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Based on record reviews the licencee failed to ensure that the Administrator has knowledge of and the ability to conform to Title 22 regulations, resulting to multiple deficiencies cited,, which poses a poetential health and safety risk to residents in care.
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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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4