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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006189
Report Date: 05/17/2023
Date Signed: 06/19/2023 09:01:42 AM

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
12/12/2022 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20221212121518
FACILITY NAME:KAEGO'S RICHMAN GARDENSFACILITY NUMBER:
306006189
ADMINISTRATOR:HARVEY, LUPEFACILITY TYPE:
740
ADDRESS:317 N. RICHMAN GARDENSTELEPHONE:
(213) 478-0460
CITY:FULLERTONSTATE: ZIP CODE:
92831
CAPACITY:26CENSUS: 22DATE:
05/17/2023
UNANNOUNCEDTIME BEGAN:
07:45 AM
MET WITH:Rosalba MaldonadoTIME COMPLETED:
09:25 AM
ALLEGATION(S):
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Licensee had liability insurance that did not include required coverage for resident’s injuries
INVESTIGATION FINDINGS:
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 This is an amended report.

This unannounced subsequent complaint inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. The LPA met with Staff #1 (S1) Rosalba Maldonado and explained the reason for today’s inspection. There was concern that the Licensee representative had liability insurance that did not include the required coverage for resident’s injuries.

On 12/13/2022, LPA Sean Haddad conducted the initial 10-day complaint investigation and conducted interviews from 8:00 a.m. to 12:00 p.m., along with reviewing and/or obtaining copies of the resident roster, staff roster and insurance records. Facility staff stated that this facility had liability insurance with an effective date of 08/26/2022. Further investigation was required.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
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 6
Control Number 22-AS-20221212121518
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: KAEGO'S RICHMAN GARDENS
FACILITY NUMBER: 306006189
VISIT DATE: 05/17/2023
NARRATIVE
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On 12/14/2022 the LPA reviewed the insurance records for clarification. Licensee presented multiple Certificate of Liability Insurance.

The Certificate of Liability Insurance dated 09/02/2022 for Policy Number ending in 191-0 shows an effective date of 08/26/2022 thru ending date of 8/26/2023. This corroborates with the facility staff’s statement. This certificate indicates the coverage of limits one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate. However, this certificate states that this policy is shared by this facility and six (6) other facilities, meaning this policy does not provide the required coverage of one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate for this facility.

On 12/6/2022, the Policy Number ending in 191-0 dated 9/2/2022 was rewritten into Policy Number ending in [Bentley Suites: 493-0; Henrietta’s Leven Oaks: 499-0; Kaego’s Richman Gardens: 501-0; Bentley House: 496-0; Bentley Manor: 498-0; Bentley Hills: 492-0; Henrietta’s Home: 500-0] and there was no gap between these policies since 08/26/2022 thru ending date of policy of 8/26/23. This is a separate, stand-alone business liability insurance for this facility.

An Insurance Binder dated 12/08/2022 for Policy Number ending in [Bentley Suites: 493-0; Henrietta’s Leven Oaks: 499-0; Kaego’s Richman Gardens: 501-0; Bentley House: 496-0; Bentley Manor: 498-0; Bentley Hills: 492-0; Henrietta’s Home: 500-0] identified multiple policy exclusions, including exclusions for “Infestation”, “Bedsores”, “Elopement (General Liability)”, and “Treatment of Coronavirus”. Per witness interview, the exclusion for “Bedsores” means that this policy does not cover resident injuries due to bedsores if there is evidence of negligence on the part of the Licensee. Witnesses also stated that the exclusions for “Infestation” and “Elopement (General Liability)” mean that the Licensee is not responsible for obtaining insurance for injuries to residents from infestations and elopements. Due to the exclusions, this policy does not include the required coverage for resident injuries caused by the negligent acts or omissions to act of, or neglect by, the Licensee or its employees.

The Certificate of Liability Insurance dated 12/13/2022 for policy number ending in [Bentley Suites: 493-0; Henrietta’s Leven Oaks: 499-0; Kaego’s Richman Gardens: 501-0; Bentley House: 496-0; Bentley Manor: 498-0; Bentley Hills: 492-0; Henrietta’s Home: 500-0] shows an effective date of 12/06/2022.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 22-AS-20221212121518
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: KAEGO'S RICHMAN GARDENS
FACILITY NUMBER: 306006189
VISIT DATE: 05/17/2023
NARRATIVE
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While the Licensee had insurance policies in place from 08/26/2022, the policies [Bentley Suites: 493-0; Henrietta’s Leven Oaks: 499-0; Kaego’s Richman Gardens: 501-0; Bentley House: 496-0; Bentley Manor: 498-0; Bentley Hills: 492-0; Henrietta’s Home: 500-0] did not provide the required coverage due to the exclusions they contained; and, because this facility was sharing a single policy with six (6) other facilities (Bentley Suites 198320302; Henrietta's Leven Oaks 198603586; Kaego's Richman Gardens 306006189; Bentley House 198320303; Bentley Manor 198320301; Bentley Hills 195850277; Henrietta's Home 198603585).

Based on the investigation conducted by the Department it was determined that between 08/26/2022 and 12/06/2022, this facility did not have its own liability insurance coverage that is compliant with Title 22 Regulations. As a result, the above-mentioned allegation is being substantiated. Please see LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

This is an amended report.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 22-AS-20221212121518
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: KAEGO'S RICHMAN GARDENS
FACILITY NUMBER: 306006189
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
05/24/2023
Section Cited
HSC
1569.605
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… all residential care facilities for the elderly … shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee
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Licensee stated they will obtain liability insurance that complies with Health & Safety Code section 1569.605 and submit proof to LPA by POC due date.
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or its employees. This requirement was not met as evidenced by: Based on interviews and records review, the licensee did not maintain liability insurance covering injury to residents and guests in the amounts specified which posed an immediate Health, Safety, or Personal Rights risk to up to 26 persons 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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
12/12/2022 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20221212121518

FACILITY NAME:KAEGO'S RICHMAN GARDENSFACILITY NUMBER:
306006189
ADMINISTRATOR:HARVEY, LUPEFACILITY TYPE:
740
ADDRESS:317 N. RICHMAN GARDENSTELEPHONE:
(213) 478-0460
CITY:FULLERTONSTATE: ZIP CODE:
92831
CAPACITY:26CENSUS: 22DATE:
05/17/2023
UNANNOUNCEDTIME BEGAN:
07:45 AM
MET WITH:Rosalba MaldonadoTIME COMPLETED:
09:25 AM
ALLEGATION(S):
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Licensee misrepresented to the Department that they have liability insurance
The Licensee has no current liability insurance
INVESTIGATION FINDINGS:
1
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3
4
5
6
7
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10
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13
 This is an amended report.

This unannounced subsequent complaint inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegations. The LPA met with Staff #1 (S1) Rosalba Maldonado and explained the reason for today’s inspection. There was concern that the Licensee representative misrepresented to the Department that they had liability insurance.

On 12/13/2022, LPA Sean Haddad conducted the initial 10-day complaint investigation and conducted interviews from 8:00 a.m. to 12:00 p.m., along with reviewing and/or obtaining copies of the resident roster, staff roster and insurance records. Interviews conducted with facility staff and witnesses revealed that facility was actively working with multiple insurance agencies to finalize the policy to comply with Title 22 Regulations.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 22-AS-20221212121518
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: KAEGO'S RICHMAN GARDENS
FACILITY NUMBER: 306006189
VISIT DATE: 05/17/2023
NARRATIVE
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The licensee had current liability insurance, however this facility did not have its own liability insurance. Based on review of the policies submitted to the Department between 08/26/2022 and 12/06/2022 there is insufficient information to support the allegations.

An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

This is an amended report.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6