306005653-7-14-2023-22-AS-SSAS-CU327C-20230724170828

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005653
Report Date: 07/14/2023
Date Signed: 07/14/2023 12:26:19 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
07/07/2023 and conducted by Evaluator Jerome Haley

COMPLAINT CONTROL NUMBER: 22-AS-20230707072628

FACILITY NAME:	CARE ADDISON		FACILITY NUMBER:	306005653
ADMINISTRATOR:	FISCHER, LONNIE		FACILITY TYPE:	740
ADDRESS:	19982 AVENIDA PUESTA DEL SOL		TELEPHONE:	(714) 393-2308
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY:	0	CENSUS: 0	DATE:	07/14/2023
		UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Lonnie Fischer - Licensee		TIME COMPLETED:	12:35 PM

ALLEGATION(S):

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Facility failed to provide refund to responsible party

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jerome Haley conducted this initial 10-day complaint visit with Licensee Lonnie Fischer. Care Addison (306005653) was closed June 8, 2022, so this visit was conducted at Avalon Bagels to Burgers: 174 Yorba Linda Blvd Placentia, CA. 92870.
During the complaint visit LPA Haley met and conducted an interview with Licensee Fischer.

Regarding the complaint allegation, Licensee Fischer was contacted by the Responsible Party (RP) of a resident in the facility who just passed away December 9, 2020. The RP sent a text message to the licensee December 9, 2020 requesting a refund for the month of December for the friend who recently passed away. Licensee Fischer called the RP back, but did not get through, and did not receive a call back. Licensee Fischer then sent a text to RP December 18, 2020 and asked for a phone call to set up payment arrangements for the refund. RP failed to respond, so a refunded was not provided.

Continued on LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

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-20230707072628

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: CARE ADDISON	FACILITY NUMBER: 306005653
	VISIT DATE: 07/14/2023

NARRATIVE

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The investigation revealed a refund was not provided to the RP in a timely manner. However, LPA Haley was made aware, provided evidence, and confirmed the issues was resolved between Licensee Fischer and the RP. A refund was provided to the RP.

Based on LPA Haley observations and interview confirmation, the preponderance of evidence standard has been met, therefore the complaint allegation is deemed SUBSTANTIATED.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20230707072628

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: CARE ADDISON	FACILITY NUMBER: 306005653
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/14/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/14/2023 Section Cited CCR 87507(5)(A)	1 2 3 4 5 6 7	Admission Agreement- Facility policy concerning refunds, including the conditions under which a refund for advanced monthly fees will be returned in the event of a resident’s death, pursuant to Health and Safety Code section 1569.652.	1 2 3 4 5 6 7	Licensee Lonnie Fischer has resolved this matter and the refund has been issued. LPA Haley was provided information that confirms this to be true.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: based on observation and interviews, the licenee did not return the Responsible Party's refund. This poses a potential risk to the health & safety of residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC9099 (FAS) - (06/04)

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