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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286803041
Report Date: 02/13/2024
Date Signed: 02/13/2024 09:39:41 AM

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
11/13/2023 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20231113100537
FACILITY NAME:LA HOMA GUEST HOME, LLCFACILITY NUMBER:
286803041
ADMINISTRATOR:DASTGHEIB, ALIFACILITY TYPE:
740
ADDRESS:1161 LA HOMA DRIVETELEPHONE:
(707) 252-7426
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:6CENSUS: 6DATE:
02/13/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Raymond GoTIME COMPLETED:
09:55 AM
ALLEGATION(S):
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Licensee did not provide a refund upon resident’s death.
INVESTIGATION FINDINGS:
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At approximately 9:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to deliver findings for an investigation conducted into the above allegation. LPA met with Administrator Raymond Go. Based on a review of records and interviews conducted, Licensee did not provide a refund in the full amount due to the residents responsible party after their death. After discussions with Administrator, the full amount due was sent to the responsible party.
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 Raymond Go 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: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024
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-20231113100537
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: LA HOMA GUEST HOME, LLC
FACILITY NUMBER: 286803041
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/01/2024
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 individual ...contractually responsible for the
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Licensee issued the full amount due to the residents estate. Licensee will review regulation 87507 Admission Agreements and submit self certification they understand and will follow regulation going forward.
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fees...to the resident’s estate, within 15 days after the personal property is removed. This requirement is not met as evidenced by: Licensee did not issue the full amount of the refund within 15 days.
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Self certification to be sent to CCL by POC date of 03/01/2024.
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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: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024
LIC9099 (FAS) - (06/04)
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