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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312701038
Report Date: 09/13/2023
Date Signed: 09/13/2023 11:13:26 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/20/2023 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 59-AS-20230720161339
FACILITY NAME:MISTY WOOD SENIOR CARE LLCFACILITY NUMBER:
312701038
ADMINISTRATOR:IANCU, MARINAFACILITY TYPE:
740
ADDRESS:1626 MISTY WOOD DRTELEPHONE:
(916) 889-2039
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 4DATE:
09/13/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Marina Iancu, Administrator TIME COMPLETED:
11:25 AM
ALLEGATION(S):
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Staff did not provide a proper written notice of resident's rate increase to Resident's Representative.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to continue investigation into allegations listed above. LPA met with Administrator Marina Iancu during today's inspection.
LPA investigated allegation listed above. LPA conducted interviews and conducted a file review. LPA obtained a copy of letter of rate increase provided to R1's representative. R1 required a higher level of care and administrator provided a letter which explained the new care that was required for R1. The letter did not provide a itemization of the charges. Due to the information gathered, LPA finds allegation to be SUBSTANTIATED.
Deficiencies cited on 9099-D.
Exit interview and appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
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 4
Control Number 59-AS-20230720161339
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: MISTY WOOD SENIOR CARE LLC
FACILITY NUMBER: 312701038
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/22/2023
Section Cited
CCR
1569.657(a)
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§1569.657. Rate increase due to change in level of resident care; notice. (a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges.
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Administrator to provide LPA a written statement of understanding to health and safety code 1569.657. Letter of statement to be provided to LPA by 9/22/23.
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This requirement is not met as evidenced by: Based on record review the licensee did not provide itemization of resident charges to R1's representative which poses potential personal rights risk to residents 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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/20/2023 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 59-AS-20230720161339

FACILITY NAME:MISTY WOOD SENIOR CARE LLCFACILITY NUMBER:
312701038
ADMINISTRATOR:IANCU, MARINAFACILITY TYPE:
740
ADDRESS:1626 MISTY WOOD DRTELEPHONE:
(916) 889-2039
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 4DATE:
09/13/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Marina Iancu, Administrator TIME COMPLETED:
11:25 AM
ALLEGATION(S):
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Facility retained a resident with a higher level of care needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to continue investigation into allegations listed above. LPA met with Administrator Marina Iancu during today's inspection.
LPA investigated allegation listed above. LPA conducted interviews and conducted a file review. LPA reviewed R1’s needs and service plan and LIC602 and found no prohibited healthcare conditions. In addition, LPA found R1 was receiving hospice care services. Administrator stated R1 was mostly independent with care until R1 began to decline due to hospice admitting diagnosis. Administrator stated that caregivers helped R1 with whatever care services she needed. LPA found allegation to be UNFOUNDED.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/20/2023 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 59-AS-20230720161339

FACILITY NAME:MISTY WOOD SENIOR CARE LLCFACILITY NUMBER:
312701038
ADMINISTRATOR:IANCU, MARINAFACILITY TYPE:
740
ADDRESS:1626 MISTY WOOD DRTELEPHONE:
(916) 889-2039
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 4DATE:
09/13/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Marina Iancu, Administrator TIME COMPLETED:
11:25 AM
ALLEGATION(S):
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Staff did not provide a copy of resident's Admission Agreement to their representative upon request.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to continue investigation into allegations listed above. LPA met with Administrator Marina Iancu during today's inspection.
LPA investigated allegation listed above. LPA conducted interviews and conducted a file review. LPA interviewed administrator in which she stated she never received a request from R1's representative to obtain a copy of residents admission agreement. Relevant party states a request for R1's admission agreement was made and administrator never provided. Due to the conflicting information, LPA finds allegation to be UNSUBSTANTIATED.
Exit interview provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4