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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 247209209
Report Date: 09/21/2022
Date Signed: 11/22/2022 03:44:43 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, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/14/2022 and conducted by Evaluator Alexandria Walton
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20220914194055
FACILITY NAME:ATWATER RESIDENTIAL CARE FACILITYFACILITY NUMBER:
247209209
ADMINISTRATOR:JOHNSON, JESSICAFACILITY TYPE:
740
ADDRESS:1691 JOE SILVA AVENUETELEPHONE:
(209) 430-1688
CITY:ATWATERSTATE: CAZIP CODE:
95301
CAPACITY:5CENSUS: 3DATE:
09/21/2022
UNANNOUNCEDTIME BEGAN:
09:42 AM
MET WITH:Caregiver, Arlene AngelesTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not refund fees to resident who decided not to enter the facility
INVESTIGATION FINDINGS:
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This is an amended report.

On 09/21/2022, Licensing Program Analyst (LPA) Walton conducted an unannounced complaint investigation visit. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Facility staff contacted Administrator via telephone, and she was unable to attend but gave LPA verbal permission to meet with Caregiver, Arlene Angeles. LPA delivered findings of the complaint, whose signature on the original report, confirms receipt.

Today, 11/16/2022, LPA Walton and Licensing Program Manager (LPM) Melinda Hoffmann contacted Administrator via telephone and informed her that the report is being amended as follows. CONTINUED TO 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
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 24-AS-20220914194055
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: ATWATER RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 247209209
VISIT DATE: 09/21/2022
NARRATIVE
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This is an amended report.

During the course of the investigation, LPA interviewed Administrator, Resident #1's (R1) responsible party (RP), and reviewed records, including but not limited to the admission agreement provided to RP. Based on interviews and records review, a preadmission appraisal was not completed by facility, resident did not end up moving into the facility, and as of 9/21/22, facility had not issued a refund of the $500 preadmission fee. The preponderance of evidence standard was met and the allegation: Staff did not refund fees to resident who decided not to enter the facility was SUBSTANTIATED. A deficiency was cited in accordance with California Code of Regulations, Title 22, Division 6 on the attached 9099D.

Administrator was informed that a copy of this report will be emailed to her for signature, as will a clearance letter for the above deficiency as it has been verified that the refund of $500 was issued to RP subsequent to the deficiency.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20220914194055
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: ATWATER RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 247209209
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2022
Section Cited
CCR
87507(g)(5)(E)
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(g) Admission agreements shall specify the following...(5) Refund conditions...(E) Preadmission fees shall be refunded according to the following conditions: 1. A 100 percent refund of a preadmission fee shall be provided to an applicant or the applicant’s representative if: a. The applicant decides not to enter the facility prior to the facility completing a preadmission appraisal...b. The licensee fails to provide full written disclosure of preadmission fee charges and refund conditions. This requirement was not met as evidenced by:
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Licensee agrees to refund $500 to R1 by the POC due date and submit proof that refund was given to the Fresno CCL office.
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Based on interviews and records review, the facility did not ensure 100 percent of the $500 admission fee was refunded to R1, which poses a potential health and safety risk to persons in care.
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Licensee agreed to submit a signed written statement acknowledging that the Licensee will amend the facility admission agreement to include language regarding holding fees and the terms for refund and said language must be in accordance with section 87507.
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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: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3