286801534-6-29-2022-21-AS-HDBI-CGB34Y-20220713175555

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 286801534
Report Date: 06/29/2022
Date Signed: 06/29/2022 01:06:59 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
06/02/2022 and conducted by Evaluator Victoria Willis

COMPLAINT CONTROL NUMBER: 21-AS-20220602110837

FACILITY NAME:	WINE COUNTRY SENIOR'S VILLA		FACILITY NUMBER:	286801534
ADMINISTRATOR:	CRUZ, TERRY & ROA, F		FACILITY TYPE:	740
ADDRESS:	3552 JEFFERSON ST.		TELEPHONE:	(707) 226-3055
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY:	6	CENSUS: 4	DATE:	06/29/2022
		UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Licensee, Francisco Roa		TIME COMPLETED:	01:16 PM

ALLEGATION(S):

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Facility did not issue a refund

INVESTIGATION FINDINGS:

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LPA Willis arrived unannounced to deliver findings regarding the above mentioned complaint allegation and met with caregiver, Privado Magno. Licensee, Francisco Roa arrived later.

During investigation. LPA conducted file review and spoke with Licensee.

Facility did not issue a refund – Complaint alleges that upon death of a resident, the responsible party was not provided a refund. Complaint goes on to allege that when a refund was requested, the facility refused to issue a refund prompting the responsible party to leave the resident’s personal belongings in their room. When responsible party came to pick up personal belongings at the end of the month, resident’s belonging had been removed from the resident’s room and put in the garage. Interview with Licensee confirmed that they did refuse to issue a refund to responsible party and confirmed that they removed the resident’s personal items from their room and placed them in the garage.

Continued on LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022

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 21-AS-20220602110837

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: WINE COUNTRY SENIOR'S VILLA	FACILITY NUMBER: 286801534
	VISIT DATE: 06/29/2022

NARRATIVE

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Continued from LIC9099

Health and Safety Code section 1569.652 requires that resident’s responsible party is refunded any fees paid in advance covering the time after the resident’s personal property has been removed from the facility. Review of the Admission Agreement confirmed that the agreement was terminated once "all resident's personal belongings, furniture and medical equipment have been removed from the facility." In this case, the resident’s personal belongings were not removed from the facility as the garage is considered part of the facility. While it is not possible to determine what date the personal belongings would have been removed from the facility by the responsible party had the Licensee given them correct information, Licensee did refuse a refund.

The allegation that the facility did not issue a refund is Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20220602110837

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: WINE COUNTRY SENIOR'S VILLA	FACILITY NUMBER: 286801534
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/29/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/15/2022 Section Cited HSC 1569.652	1 2 3 4 5 6 7	Termination of admission agreement upon death of resident..RCFE shall not require advance notice for terminating an admission agreement upon death of a resident. No fees shall accrue once all property belonging to deceased resident is removed from the living unit..A refund or any fees paid in advance covering the time after the resident's property	1 2 3 4 5 6 7	Licensee agrees to update all Admission Agreements to include language from Health and Safety Code 1569.652 to ensure that all resident's and their responsible parties are aware of their rights upon death of a resident. Licensee to send copy of addendum with signature or resident or their responsble party to CCL by POC due date, 7/15/2022.
	8 9 10 11 12 13 14	has been removed from the facility shall be issued...within 15 days after property is removed..If fees are assessed while resident’s property remains in unit after resident is deceased, licensee shall, within 3 days of becoming aware of the death, provide..written notice of the facility’s policies re:contract termination... Requirement has not been met.	8 9 10 11 12 13 14
	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: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022

LIC9099 (FAS) - (06/04)

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