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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306001157
Report Date: 09/25/2020
Date Signed: 09/25/2020 06:05:38 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
08/04/2020 and conducted by Evaluator Ruth Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20200804162856
FACILITY NAME:PARK TERRACEFACILITY NUMBER:
306001157
ADMINISTRATOR:KOEHLER, EUGENE (GENO)FACILITY TYPE:
740
ADDRESS:21952 BUENA SUERTETELEPHONE:
(949) 888-2250
CITY:RANCHO SANTA MARGARISTATE: CAZIP CODE:
92688
CAPACITY:230CENSUS: 177DATE:
09/25/2020
UNANNOUNCEDTIME BEGAN:
04:34 PM
MET WITH:Geno KoehlerTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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• Facility failed to give adequate notice for change in resident’s level of care
• Facility is not following resident’s admission agreement resulting in billing errors
• Residents admission agreement is not written in clear language
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ruth Martinez contacted the facility via tele-visit due to COVID-19 precautionary measures to deliver findings for the investigation into the above identified complaint allegations. LPA spoke with Geno Koehler, Administrator and explained the purpose of the telephone call.
The findings are based upon an investigation which included interviews with staff, interviews with six residents, and a review of resident’s records. It is alleged that facility failed to give adequate notice for change in resident’s level of care, facility is not following resident’s admissions agreement resulting in billing errors and resident’s admissions agreement is not written in clear language. LPA Martinez obtained a Level of Care Notification for resident #1 (R1) stating effective 07/12/2020 rate change for a level of care provided. However, notice was signed by community staff 07/16/2020 and the following was stated, “spoke with resident’s responsible party via phone 07/16/2020.” Regardless of level of care charged, facility did not provide adequate notice to change of fee.


Continued on LIC9099-C

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2020
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 5
Control Number 22-AS-20200804162856
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: PARK TERRACE
FACILITY NUMBER: 306001157
VISIT DATE: 09/25/2020
NARRATIVE
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As required in health and Safety Code section 15969.657 (a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. Here, the notice was provided on 07/16/2020, four business days after the effective date of 07/12/2020. R1’s admissions agreement and care plan effective date of 01/31/2019 states R1 entered facility at level 4 with a note stating, “to be re-evaluated at the end of February.” The care plan date 03/04/2019 reflects level 2 care, but the level of care notification at that time stated level 1 due to typographical error. This means R1 was receiving level 2 care but paying for level 1, which was a billing error. The billing error was related to the performance of the admissions agreement in that if the agreement had been followed, the billing error and resulting increase in price would not have occurred. The admission agreement outlines a total price which includes a base price and an additional price for a resident’s level of care. To determine the level of care, the Facility takes a resident’s LIC602, nurse evaluation, and family input and logs this information into a computer system. The computer system then outputs a care plan with a corresponding level of care, with each of the 5 levels of care having a different price. The care plan lists specific items of care or assistance with their corresponding frequency. According to the administrator, each item has a pre-assigned point value based on the time spent by staff. When the points are all added up, a total point value is determined. Each level of care apparently has a point range. When a resident’s total point value falls within the range of a level of care, the resident is assigned to that level of care and charged that price. However, the residents are not told what the ranges of the levels are. Thus, the agreement ensures the residents are not able to determine where their care plan falls within the range of their level of care and are unable to determine what possible changes to their care plan might effectuate a drop or increase to a different level. Because the care plan and level system are incorporated into the admissions agreement, the admission agreement is not written in clear language.
During the course of the investigation, there was sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Administrator via tele-visit a copy of the report along with appeal rights was sent via email and an electronic email read receipt confirms receiving of the report. Administrator agrees to review, agrees to send the signed report via email.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
08/04/2020 and conducted by Evaluator Ruth Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20200804162856

FACILITY NAME:PARK TERRACEFACILITY NUMBER:
306001157
ADMINISTRATOR:KOEHLER, EUGENE (GENO)FACILITY TYPE:
740
ADDRESS:21952 BUENA SUERTETELEPHONE:
(949) 888-2250
CITY:RANCHO SANTA MARGARISTATE: CAZIP CODE:
92688
CAPACITY:230CENSUS: 177DATE:
09/25/2020
UNANNOUNCEDTIME BEGAN:
04:34 PM
MET WITH:Geno KoehlerTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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• Resident did not have a change in level of care warranting a fee increase
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ruth Martinez contacted the facility via tele-visit due to COVID-19 precautionary measures to deliver findings for the investigation into the above identified complaint allegation. LPA spoke with Administrator and explained the purpose of the telephone call.
The findings are based upon an investigation which included interviews with staff, interviews with six residents, and a review of resident’s records. It is alleged that resident did not have a change in level of care warranting a fee increase. Even though R1’s level of care did not change, the fee that was charged was not for a level that was not rendered but rather received a higher level of care from 03/04/2019 to 07/12/2020. As a result of billing error R1 benefited being received a higher level of care that was not billed for.
Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated.
A copy of this report is being reviewed with Administrator and a copy of this LIC9099 furnished to the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20200804162856
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: PARK TERRACE
FACILITY NUMBER: 306001157
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/02/2020
Section Cited
HSC
15969.657(a)
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Rate increase due to change in level of resident care; notice: For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business day after initially services at the new level of care...etc. This requirement
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Administrator agrees to read regulation and sign a statement of understanding and forward proof to LPA by POC due date.
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was not met as evidenced by notice provided on 07/16/2020, four business days after the effective date of 07/12/2020. Regardless of level of care charged, facility did not provide adequate notice to change of fee. This poses a personal right risk to resident in care.
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Type B
09/25/2020
Section Cited
CCR
87507(f)
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Admission Agreements. The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This regulation was not met as evidenced by: R1 was receiving level 2 care but paying for level 1, which was a billing error. The billing error was related to the
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Administrator agrees to read regulation and sign a statement of understanding and forward proof to LPA by POC due date.
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performance of the admissions agreement in that if the agreement had been followed, the billing error and resulting increase in price would not have occurred. This poses a potential personal right to resident in care.
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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: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20200804162856
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: PARK TERRACE
FACILITY NUMBER: 306001157
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/25/2020
Section Cited
CCR
87507(1)(a)(B)
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Admissions Agreement. Written in clear, understandable, coherent, and unambiguous language, using words with common and everyday meanings, and shall be appropriately divided with each section appropriately titled. This regulation was not met as evidenced by the care plan and level system incorporated into the admissions
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Administrator agrees to read regulation and sign a statement of understanding and forward proof to LPA by POC due date.
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agreement lacking clear description of the ranges for each level of care determining the cost charged to residents. This poses a potential personal right to resident in care.
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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: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 5