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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005530
Report Date: 03/30/2023
Date Signed: 03/30/2023 01:50:54 PM

Unfounded


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
03/17/2023 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230317115338
FACILITY NAME:VIVIDUS SENIOR LIVINGFACILITY NUMBER:
306005530
ADMINISTRATOR:SHARIFAN, BAABAKFACILITY TYPE:
740
ADDRESS:25572 MAXIMUS STTELEPHONE:
(949) 584-0920
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
03/30/2023
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Edgar SevillaTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff did not refund resident fees.
Staff did not provide resident's records to resident's authorized person.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation. LPA met with Staff Edgar Sevilla and explained the reason for the visit. The investigation into the allegation, staff did not refund resident fees, revealed the following. Resident 1 (R1) had paid rent for December 2022 on 11/19/22. R1 passed away on 11/22/22. R1 had no Power of Attorney (POA) and no family listed on any of their facility documents. R1 had an Advance Health Care Directive naming only an appointment of a health care agent when the primary physician finds that R1 cannot make their own health care decisions. All witnesses interviewed verified that R1 made their own decisions and handled their own finances. R1’s health care agent was listed on the admission agreement as the health care surrogate decision maker and signed the admission agreement along with R1. R1’s health care agent requested a refund for the rent for December 2022. No refund was issued by the Licensee to anyone regarding R1’s rent for December 2022. The Licensee reported that R1’s belongings were removed on 11/27/22, except for R1’s bed. All witnesses interviewed verified this report.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
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 22-AS-20230317115338
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: VIVIDUS SENIOR LIVING
FACILITY NUMBER: 306005530
VISIT DATE: 03/30/2023
NARRATIVE
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Licensee reported that the health care agent contacted him on 12/13/22 leaving a voicemail message and reported the bed could not be moved and requested the facility donate it. Licensee provided the Agency with a copy of the voicemail dated 12/13/22, verifying the report. The Licensee reported that the bed would not be accepted by any charities and trash removal of the item was arranged. The bed was picked up on 12/23/22. The health care agent reported they are the trustee for the trust R1 established prior to their death. They became the trustee after R1’s death on 1/23/23. The certification of Trust for R1 has not been provided to the Licensee. This information was verified by witnesses interviewed. The Licensee is not required to issue a refund based on someone’s word when R1 had no POA, no family and no documentation has been provided to them to verify who is the Trustee of R1’s estate. Based on the evidence gathered the allegation, staff did not refund resident fees, is deemed unfounded, meaning the allegation is false could not have happened and/or is without a reasonable basis.

Regarding the allegation, staff did not provide resident’s records to resident’s authorized person, the investigation revealed the following. R1 passed away on 11/22/22. R1 did not have a Power of Attorney (POA) or any family. R1 had an Advance Health Care Directive naming only an appointment of a health care agent when the primary physician finds that R1 cannot make their own health care decisions. R1’s health care agent was listed on the admission agreement as the health care surrogate decision maker and signed the admission agreement along with R1. All witnesses interviewed verified that R1 made their own decisions and handled their own finances. R1’s health care agent requested a copy of R1’s admission agreement in December 2022. The Licensee did not provide the health care agent a copy of the admission agreement. The health care agent reported they are the trustee for the trust R1 established prior to their death and became the trustee after R1’s death on 1/23/23. The certification of Trust for R1 has not been provided to the Licensee. This information was verified by witnesses interviewed. R1 had no POA. R1 had a health care agent who was not the responsible party for R1. Based on the evidence gathered the allegation, staff did not provide resident’s records to resident’s authorized person is deemed unfounded, meaning the allegation is false could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2