198603208-4-13-2022-28-AS-MVAO-CDNKWW-20220420081637

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603208
Report Date: 04/13/2022
Date Signed: 04/13/2022 12:34:08 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
01/06/2021 and conducted by Evaluator Nicol Wesley

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210106134537

FACILITY NAME:	LOVING ARMS RESIDENTIAL CARE FOR SENIORS III		FACILITY NUMBER:	198603208
ADMINISTRATOR:	BISNAR, LOURDES		FACILITY TYPE:	740
ADDRESS:	11507 THOMAS PLACE		TELEPHONE:	(562) 864-6308
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY:	6	CENSUS: 2	DATE:	04/13/2022
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Crystal Li		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility did not issue a refund to authorized representative.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nicol Wesley conducted a subsequent complaint visit and met with Licensee Crystal Li and Administrator Lourdes Bisnar to discuss he purpose of todays visit.

The investigation consisted of the following: LPA Wesley conducted a telephonic interview with the Licensee regarding the above mentioned allegation. LPA requested a copy of: staff roster, resident roster, and the following documents for resident #1 : Admission agreement, Emergency Identification page(ID Page), current Physicians report, Appraisal needs and services plan, and the Hospice care plan.

Regarding allegation: Facility did not issue a refund to authorized representative. Resident #1 was admitted into the facility on 11/20/20 and was receiving Hospice care. On 12/18/20 resident #1 passed away while
Continued on LIC 9099C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022

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-20210106134537

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: LOVING ARMS RESIDENTIAL CARE FOR SENIORS III	FACILITY NUMBER: 198603208
	VISIT DATE: 04/13/2022

NARRATIVE

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residing in the facility. Resident #1's responsible party paid rent for the resident from 11/20/20-01/31/21 and did not receive a refund from 12/18/20-01/31/21. As of 01/06/21 the facility Administrator failed to refund resident #1's responsible party the money that was owed from 12/19/20-01/31/21. During the interview with licensee Crystal Li, she was advised that the facility is responsible for reimbursing the residents responsible party for the rent as the resident passed away on 12/18/20, all of their items were removed from the facility on the same day(12/18/20), and their rent was paid up to 01/31/21 as resident #1's family did not anticipate that the resident would expire prior to that date. Resident #1's responsible party learned the post dated check for resident #1's January 2021 rent was cashed early(12/08/20). As of 01/19/21 resident #1's responsible party informed the LPA that they have not received the full refund for resident #1's rent, informed the LPA that they received a partial refund for dates 12/19/20-12/31/20 and had to contacted the facility to request the remaining balance(refund) for the month of January 2021 and said the licensee had not been returning their phone calls. It was also reported that resident #1's responsible party had not received any communication/feedback until after they filed a complaint with Department of Social Services, Community Care Licensing Division. During the interview with Licensee Crystal Li she did not feel that the facility had to reimburse all of the funds for rent paid for resident #1 according to their agreement, and the LPA advised that the facility had to refund money to the responsible party for the rent paid to them as they cashed a check and received funds for rent up to 01/31/21 and resident #1 passed on 12/18/20. Licensee Crystal Li informed the LPA that a total of 3 checks were sent and the last check(#3) was mailed on 01/18/21.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be Substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210106134537

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: LOVING ARMS RESIDENTIAL CARE FOR SENIORS III	FACILITY NUMBER: 198603208
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/13/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/26/2022 Section Cited HSC 1569.652(c)	1 2 3 4 5 6 7	Admission Agreement A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased	1 2 3 4 5 6 7	In the future, the Licensee/Administrator shall comply with the Title 22 regulations and refund money that is due for a resident to their responsible party/POA within a reasonable time.
	8 9 10 11 12 13 14	resident paid the fees, to the resident's estate, within 15 days after the personal property is removed. This evidence was not met as required by: During the complaint investigation it was discovered that the Licensee failed to issue refund to the residents responsible party within the required time frame.	8 9 10 11 12 13 14	The licensee issued the total refund of money owed to resident#1s family in 3 separate checks. This deficiency was corrected on 01/18/21
	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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022

LIC9099 (FAS) - (06/04)

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