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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 236800970
Report Date: 06/28/2024
Date Signed: 06/28/2024 12:48:12 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, 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
06/27/2024 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20240627145847
FACILITY NAME:OBSERVATORY CARE HOMEFACILITY NUMBER:
236800970
ADMINISTRATOR:CRISTINA ALCASIDFACILITY TYPE:
740
ADDRESS:270 OBSERVATORY STREETTELEPHONE:
(707) 468-5986
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY:6CENSUS: 1DATE:
06/28/2024
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Elesio AlcasidTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility did not issue a refund to a resident.
INVESTIGATION FINDINGS:
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At approximately 11:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegation. LPA met with Licensee Eliseo Alcasid and reviewed records. Based on records reviewed and interview conducted, Licensee did not provide a refund to residents estate as required by regulation. Licensee stated he thought there was a longer time period to refund the estate. LPA provided copies of regulation regarding refunds.
Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
This report was reviewed with Licensee and Appeal rights were given.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024
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-20240627145847
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OBSERVATORY CARE HOME
FACILITY NUMBER: 236800970
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/05/2024
Section Cited
HSC
1569.652(c)
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(c) 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 resident’s estate, within 15 days after the personal
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Licensee to provide refund to residents familiy and review regulation provided by LPA. Licensee shall submit self certification that refund has been issued and the Licensee will abide by regulation.
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property is removed. This requirement is not met as evidenced by: Based on record review, Licensee did not provide refund per regulation. This poses a potential Personal rights risk to residents in care.
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Self certification to be submitted to CCL by POC date of 07/05/2024.
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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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024
LIC9099 (FAS) - (06/04)
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