306000638-2-18-2020-22-AS-MSTC-BMMT88-20200312142952

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306000638
Report Date: 02/18/2020
Date Signed: 02/18/2020 04:33:17 PM

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
02/06/2020 and conducted by Evaluator Lydia Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200206133735

FACILITY NAME:	3K HOME CARE		FACILITY NUMBER:	306000638
ADMINISTRATOR:	MARIA N.G. MANIMBO		FACILITY TYPE:	740
ADDRESS:	700 S. PLYMOUTH PLACE		TELEPHONE:	(714) 774-8653
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92806
CAPACITY:	6	CENSUS: 2	DATE:	02/18/2020
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Maria N. Manimbo		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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* Facility did not issue refund
* Facility charged resident for services not received

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced 10-day complaint visit and to render findings on above allegations. LPA Martinez was greeted and granted entry by Administrator Maria Manimbo and reason for visit was explained.

During the course of this investigation, LPA Martinez interviewed Licensee and a Witness as well as reviewed and obtained pertinent documentation such as Admission Agreement signed on 08/14/2017, Receipt #390429 dated 05/15/2017, check #1136 dated 10/30/2019, and check #1137 dated 11/30/2019 both in the amount of $2,000.00 each.

The investigation into allegation "facility did not issue a refund" is determined to be Unfounded. The investigation revealed the following: LPA obtained copies of two checks; check #1136 in the amount of $2,000.00 that was cashed on 11/12/2019 and check #1137 in the amount of $2,000.00 that was cashed on 12/16/2019.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20200206133735

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: 3K HOME CARE	FACILITY NUMBER: 306000638
	VISIT DATE: 02/18/2020

NARRATIVE

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The investigation into allegation “facility charged resident for services not received” revealed the following: LPA interviewed the witness who clarified that there were no issues with the care or service Resident 1 (R1) received from the facility, but that concern was raised as the refund was not received, meaning that the billing was issued for services not rendered. However, the refund has been received making this allegation Unfounded.

Based on evidence gathered during this investigation both allegations are deemed Unfounded. This agency has investigated allegations and are both found to be Unfounded, meaning the allegations were false, could not have happened or/are without a reasonable basis. Therefore, they are dismissed.

This repot was discussed with the facility representatives and a copy of this report and LIC 811, which identifies confidential names was provided

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2020

LIC9099 (FAS) - (06/04)

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