210108102-4-3-2024-21-AS-VBEI-D45SY4-20240408141652

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 210108102
Report Date: 04/03/2024
Date Signed: 04/03/2024 12:37:56 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/14/2023 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20231214130351

FACILITY NAME:	VILLA MARIN AMBULATORY CARE UNIT		FACILITY NUMBER:	210108102
ADMINISTRATOR:	DURANCZYK, PAUL		FACILITY TYPE:	741
ADDRESS:	100 THORNDALE DRIVE		TELEPHONE:	(415) 499-8711
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	28	CENSUS: 14	DATE:	04/03/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator, Paul Duranczyk		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Licensee has not issued a refund to resident's authorized representative

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

At approximately 9:00AM, Licensing Program Analysts (LPAs) Felias and Florio arrived unannounced to continue a Complaint Investigation regarding the above allegation and met with Administrator, Paul Duranczyk.

During the course of the investigation, the Department reviewed and requested documents, conducted interviews, and made observations. There is an allegation that Licensee has not issued a refund to resident's authorized representative. Review of documents show that Resident 1 (R1) passed on March 24, 2023. The investigation revealed that R1 moved from an independent condominium to a double occupancy PCU (Personal Care Unit) room on September 4, 2022. Facility documents revealed that R1’s authorized representative requested to have a single occupancy room or private room for R1.

Continued on LIC9099C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

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 2

Control Number 21-AS-20231214130351

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VILLA MARIN AMBULATORY CARE UNIT	FACILITY NUMBER: 210108102
	VISIT DATE: 04/03/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC9099

Facility documents indicated that R1 had single room accommodation starting 10/26/2022 but did not pay at the single room rate until January 2023, creating a balance of $10,859.50. Financial statements indicated that the daily rate for March 2023 was $355 per day. Interview with Administrator and review of financial statements indicated that R1 was billed until March 23, 2023 leaving 8 days of occupancy left. This was credited in the amount of $2,849.29 which was applied to R1’s outstanding balance from November and December 2022, therefore, a refund was not issued as there was no refund due. Review of R1’s Medical Contract Version 5 dated 05/25/2016, under Part V. Covered Services and Covered Supplies stated “…SNF and PCU Care shall be in a semi-private room…” and Part VI. Exclusions stated, “The following are excluded from the Residents coverage under this contract. Their costs shall be borne by the Resident to the extent not covered by Medicare, private insurance, or other resources…surcharges for a private room are excluded…” Based on documents reviewed, interviews conducted, and observations made, this allegation is UNFOUNDED.

A finding that the Complaint is Unfounded means that the allegation was false, could not have happened and/or is without a reasonable basis.

No Deficiencies cited during visit.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2