306005782-6-12-2024-22-AS-LMOA-D6937D-20240614175947

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005782
Report Date: 06/12/2024
Date Signed: 06/12/2024 12:41:35 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
06/06/2024 and conducted by Evaluator Jessica Cho

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240606140114

FACILITY NAME:	RESPIT MANOR MISSION VIEJO		FACILITY NUMBER:	306005782
ADMINISTRATOR:	MENDEZ, MARK		FACILITY TYPE:	740
ADDRESS:	23412 VIA GUADIX		TELEPHONE:	(949) 331-7578
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 3	DATE:	06/12/2024
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Mark Mendez- Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility staff did not refund the residence fees paid after a resident passed away.

INVESTIGATION FINDINGS:

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LIcensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of initiating the 10-day complaint investigation into the above allegation. LPA was greeted and granted entry by Caregiver Michael Dorin Abada and stated the purpose of the visit. Administrator (Admin) Mark Mendez was also advised of the visit upon arrival approximately 9:30am. During the course of the investigation, LPA interviewed Administrator Mendez and obtained pertinent documentation which includes the Resident Roster, Face Sheet, Physician's Report, Hospice Records, Admission Agreement, and Billing Invoices from January to April 2024 pertaining to Resident #1 (R1) in addition to the screenshots of the text messages exchanged between the Admin and R1's family member. Additional docuementations that were verbally requested will be sent to LPA's email by close of business June 13, 2024.

The investigation revealed the following:

It is alleged that the facility staff did not refund the residence fees paid after a resident passed away.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

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-20240606140114

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: RESPIT MANOR MISSION VIEJO	FACILITY NUMBER: 306005782
	VISIT DATE: 06/12/2024

NARRATIVE

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Per the hospice records dated June 12, 2024, R1 passed away on March 14, 2024. R1 was not refunded upon death for the remainder of March 2024 as agreed per the Admission Agreement dated and signed on July 3, 2023. R1 was also additionally billed for April 2024 in the amount of $4,000.00 after their passing. Admin confirmed and agreed to reimburse a portion of March 2024 and the full amount for the April 2024. The demand amount is of $5,500.00. Admin stated that the $1,000 was reimbursed and facility now currently owes $4,500.00.

Therefore, based on the interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Facility staff did not refund the residence fees paid after a resident passed away is deemed SUBSTANTIATED as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. A deficiency is being cited on the attached LIC9099D.

An exit interview was conducted with Administrator Mark Mendez, and a copy of this report including the LIC9099C, LIC811, and the appeal rights were provided at the end of the visit.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20240606140114

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: RESPIT MANOR MISSION VIEJO	FACILITY NUMBER: 306005782
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/12/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/30/2024 Section Cited CCR 87507(g)(5)(A)	1 2 3 4 5 6 7	87507 Admission Agreements (g) Admission agreements shall specify the following: (5) Refund conditions. (A) 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. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator stated that they will issue the refund of $4500 and ensure that the $1000 that was issued is withdrawn and will provide proof of reimbursement in the amount of $5500 to LPA via email by POC due date.
	8 9 10 11 12 13 14	Based on interviews and record review, facility did not issue a refund for R1 for part of March 2024 and the entire month for April 2024 which poses a potential Personal Rights risk to persons 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: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

LIC9099 (FAS) - (06/04)

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