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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603163
Report Date: 10/27/2022
Date Signed: 10/27/2022 04:53:57 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
04/15/2020 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200415133935
FACILITY NAME:CALIFORNIA MISSION INN - ROSE MANORFACILITY NUMBER:
198603163
ADMINISTRATOR:LOPEZ, GINAFACILITY TYPE:
740
ADDRESS:4825 EARLE AVETELEPHONE:
(626) 287-0438
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY:85CENSUS: 37DATE:
10/27/2022
UNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Ruby Magao, Wellness DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff is overcharging resident while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to investigate and deliver findings on the above allegations. The purpose of the visit was discussed with Wellness DIrector Ruby Magao.
The investigation consisted of: On 4/21/2020, due to Coronavirus Disease 2019 (COVID-19) LPA Elizabeth Irra initiated a telephonic complaint investigation with former Administrator Lori Waters. The following documents were requested, but NOTobtained on 4/21/2020: Resident and staff rosters including contact information, a list of Residents that have receive an eviction notice in the past 3 months. R-1's: Face Sheet with contact information, Admission Agreement including any addendums, Appraisal Needs and Services Plan (most current), Daily Notes (if applicable) and Physician Report (most current). Staff records-schedule for March 2020 and April 2020, Staff contact numbers, Staff training on Mandating Reporting and Resident Rights. During today’s visit, some of the requested documents (financial/transaction records) and other pertinent documents were obtained. NOTE: Facility file was found incomplete in storage. Staff (S2 – S6) and family member (F1) were interviewed.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
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-20200415133935
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: CALIFORNIA MISSION INN - ROSE MANOR
FACILITY NUMBER: 198603163
VISIT DATE: 10/27/2022
NARRATIVE
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Allegation: Staff is overcharging resident while in care. It is alleged that resident (R1) was overcharged monthly rent fees after moving from sister facility "California Mission Inn #198603161" located in the same property campus. The resident moved in to the sister facility on 10/29/2019. R1 required more assistance and was charged an additional $1,600 in care level fees. Per "Basic Provisions -Resident Admission Agreement" Schedule A, the basic room and board rate total was $2,400, with an additional $1,600 rate fee for level 5 care fees; totaling $4,000 per month. On 2/29/2020, resident (R1) moved in to this facility and was no longer provided care assistance. Therefore, R1 was no longer supposed to pay $1,600 in care fees. The new monthly rent fee was $2,400, effective 2/29/2020. However, the facility continued to charge R1 care fees and the resident paid $4,180 (March 2020) and $4,000 (April 2020), but should have only paid the basic monthly fee of $2,400. Per document review, the resident's Admission Agreement was not amended to reflect the facility move or rate fee changes. Former Administrator Laura Waters, stated she spoke to the resident and was going to review the file to determine if there was a discrepancy in rent charges. However, rent fee clarification was never provided. Staff interviews confirmed that when the resident moved to this facility it no longer received care assistance, and the care fees would not be applicable. Per PCC Point Clique Care System Transaction Report it was confirmed that the resident was overcharged. Resident (R1) moved out of the facility on 6/1/2020. The total refund amount due to resident (R1) is $3,306.80.

Based on record review, and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8, Article 05.


An exit interview was conducted with Wellness Director Ruby Magao. A copy of the report an appeal rights were provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20200415133935
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: CALIFORNIA MISSION INN - ROSE MANOR
FACILITY NUMBER: 198603163
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/24/2022
Section Cited
CCR
87507(f)
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Admission Agreements. The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments.

This requirement was not met evidenced by:
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Licensee shall reimburse R1 the overcharged rent amount totaling $3,306.80. Administration staff shall certify mail a check to R1 and provide proof that the money has been reimbursed.
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Based on record review the findings indicate R1 was overcharged for months March 2020 and April 2020, after moving to this facility from Massey Hall. The resident continued to be billed and paid for care fees that it was no longer receiving.
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Type B
11/24/2022
Section Cited
CCR
87507(d)
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Admission Agreements. The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This requirement was not met evidenced by:
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Licensee shall ensure all former resident records are stored intact /complete. In addition, if a resident is moved from one facility to another, the resident and/or responsible party must be re-issued a new Admission Agreement.

Submit a written statement of protocols that will be implemented, and proof of staff training.
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Based on observation of file/record review, the facility failed to issue a new admission agreement and/or modify the original admission agreement when R1 moved to this facility from the sister facility in the same campus. There is no record of changes in the rent fees.
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3