306005806-11-15-2023-22-AS-SSAS-CZYRYH-20240130122622

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005806
Report Date: 11/15/2023
Date Signed: 11/15/2023 12:39:13 PM

Unsubstantiated

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
11/06/2023 and conducted by Evaluator Celine DePerio

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20231106105621

FACILITY NAME:	WE CARE SENIOR LIVING		FACILITY NUMBER:	306005806
ADMINISTRATOR:	SANSANO, CHERRYL		FACILITY TYPE:	740
ADDRESS:	24322 BARK ST.		TELEPHONE:	(949) 446-9841
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	6	CENSUS: 5	DATE:	11/15/2023
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Facility Administrator - Cherryl Sansano		TIME COMPLETED:	01:05 PM

ALLEGATION(S):

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Facility failed to issue a refund

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced 10-day visit to the facility for the complaint received on 11/06/2023, and to deliver the findings. LPA De Perio explained the purpose of today's visit, was greeted, and granted entry by staff on duty, and met with facility administrator (AD) Cherryl Sansano.

During the investigation, LPA De Perio toured the physical plant of the facility, conducted interviews, and requested copies of pertinent records reviewed.

It was alleged that facility failed to issue a refund. On November 1, 2023, AD sent a refunded check with the amount of $1,693.55, after the resident (R1) passed away on October 13, 2023. It was revealed in the interviews conducted with staff that from October 13, 2023, to October 17, 2023, the hospice bed in R1’s room was still present, and that hospice had picked it up on October 17, 2023.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

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-20231106105621

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: WE CARE SENIOR LIVING	FACILITY NUMBER: 306005806
	VISIT DATE: 11/15/2023

NARRATIVE

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LPA contacted Valley Oaks hospice agency, who stated that an agreement was made between R1’s family and hospice, that hospice would reimburse R1’s family for the dates of October 16, 2023 and October 17, 2023 due to not picking up the hospital bed, hoyer lift, oxygen and side table which was provided by hospice, from October 13, 2023 to October 17, 2023. It was verified by hospice that a reimbursement check for the amount of $350.00 was mailed to R1’s family on November 14, 2023.

Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation 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.

An exit interview was conducted with AD Sansano.

A copy of this report was explained and provided.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC9099 (FAS) - (06/04)

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