198602887-11-6-2020-11-AS-AJKK-BVVS4X-20201201123324

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602887
Report Date: 11/06/2020
Date Signed: 11/06/2020 08:15:02 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 DR #100
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/20/2020 and conducted by Evaluator Jey Cardenas

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20201020133028

FACILITY NAME:	SUNRISE ASSISTED LIVING OF HERMOSA BEACH		FACILITY NUMBER:	198602887
ADMINISTRATOR:	MORRIS, TRAVIS		FACILITY TYPE:	740
ADDRESS:	1837 PACIFIC COAST HWY		TELEPHONE:	(310) 937-0959
CITY:	HERMOSA BEACH	STATE: CA	ZIP CODE:	90254
CAPACITY:	142	CENSUS: 79	DATE:	11/06/2020
		UNANNOUNCED	TIME BEGAN:	05:07 PM
MET WITH:	Ami Mehta		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Staff failed to issue refund

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jey Cardenas conducted a subsequent complaint contact to deliver complaint finding regarding the allegation: Staff failed to issue a refund. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Resident Care Director, Ami Mehta.

On 10/26/2020 LPA conducted initial 10-day complaint investigation and interviewed facility administrator, Mr. Morris, LPA obtained copy of staff and resident roaster along with documentation pertinent to the allegation.
It is alleged that R1 vacated unit and personal belongings were removed from facility, however a refund has not been received by resident.

The investigation revealed the following: For allegation: Staff failed to issue refund.On 10/26/2020 LPA Cardenas interviewed Travis Morris who indicates that refund process takes about 3 ½ week. After resident vacates he completes paperwork which is forward to corporate; corporate process and sends out refund

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey Cardenas	TELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2020

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-20201020133028

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
MONTERY PARK, CA 91754

FACILITY NAME: SUNRISE ASSISTED LIVING OF HERMOSA BEACH	FACILITY NUMBER: 198602887
	VISIT DATE: 11/06/2020

NARRATIVE

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payment. Mr. Morris indicates that due to errors on move out form, a refund payment was delayed. After speaking with residents family the error was caught. On 10/20 revised move out form was sent to corporate office for processing. A check was made and sent to resident/family on 10/22. He indicates that facility didn’t deny resident a refund and facility was in communication with resident’s family.

LPA was provided with recent processed invoice showing refund payment issued. LPA also confirmed that resident’s refund payment was received with correct amount.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

A telephonic exit interview was conducted with Ami Mehta and copy of a LIC 9099 was provided via email for signature.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey Cardenas	TELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2020

LIC9099 (FAS) - (06/04)

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