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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 300612929
Report Date: 05/03/2022
Date Signed: 05/03/2022 05:44:09 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/03/2021 and conducted by Evaluator Kathrina Chin
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20210803094638
FACILITY NAME:HARTFORD HOME CAREFACILITY NUMBER:
300612929
ADMINISTRATOR:DINO ASUNCIONFACILITY TYPE:
740
ADDRESS:2424 HARTFORD AVETELEPHONE:
(562) 349-4217
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY:6CENSUS: 1DATE:
05/03/2022
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Asuncion Dino, Administrator & Arnel Dino, ManagerTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Facility mismanaged resident's funds.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Kathrina Chin made an unannounced visit to the facility on this day for the purpose of conducting a complaint investigation regarding the allegation noted above. LPA met with Asuncion Dino, Administrator and her son, Arnel Dino, facility Manager.

LPA Chin spoke to Asuncion Dino, Administrator/Licensee who stated that she charged resident 1 the amount of $1500 on March 2021, $1500 on April 2021, $1200 on May 2021 and $1200 on June 2021. The total overcharge amount is $1200. Resident 1 was interviewed but was unable to communicate to answer. LPA reviewed an admission agreement dated August 4, 2019 which indicated that R1 has a monthly rate of $1100.
(Continued on LIC 809C).
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022
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 22-AS-20210803094638
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HARTFORD HOME CARE
FACILITY NUMBER: 300612929
VISIT DATE: 05/03/2022
NARRATIVE
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Continued..


Based on LPA's observations, conducted interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.


The following deficiency is cited today as per Title 22 of the California Code of Regulations.

An exit interview was conducted along with appeal rights were provided and a copy of this report was given.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20210803094638
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HARTFORD HOME CARE
FACILITY NUMBER: 300612929
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/03/2022
Section Cited
CCR
87507(g)(3)(A)
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Admission Agreement- Rate for all basic services which the facility is required to provide in order to obtain and maintain a license. Basic services rate(s), including:
A comprehensive description of any items and services provided under a single fee, such as monthly fee for room, board and other items and services shall be listed.

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Asuncion Dino stated that she will refund the resident 1 the amount of $1200 and a copy of the check was provided to the LPA.
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This requirement was not met as evidenced by: Based on interviews, and observation, and interviews revealed : the licensee admitted that she overcharged resident 1 a total of $1200 during the months of March, April, May and June 2021. This poses a potential health, safety, and/or personal rights risk to persons in care.
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LPA’s observation and interviews with residents, staff, and witnesses revealed
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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: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3