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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315001800
Report Date: 04/09/2021
Date Signed: 04/16/2021 01:05:56 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/06/2020 and conducted by Evaluator Todd Tryon
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200506145333
FACILITY NAME:COLLEGE WAY RESIDENTIAL CAREFACILITY NUMBER:
315001800
ADMINISTRATOR:SEISA, ROYFACILITY TYPE:
740
ADDRESS:188 COLLEGE WAYTELEPHONE:
(530) 888-7475
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:15CENSUS: 3DATE:
04/09/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Delia SalcedoTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility not refunding money after resident's death
Facility not giving copies of residents' files to power-of-attorney.
INVESTIGATION FINDINGS:
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On this date, LPA Tryon spoke with house manager Delia Salcedo to complete the complaint.
While looking into the allegations, LPA learned from House Manager Delia Salcedo that she had not originally given a refund to the family of resident R1 after his death. R1's wife R2 also lived at the faclity, and was moved out right after R1 passed. According to the home, no written notice was given of moving. The family DID remove R1's beloingings from the house. The facility kept the refund owed to the family of R1, because the family did not give written notice 30 days before moving out R2. However, although LPA understands the intent of the facility actions, they cannot keep the refund of one resident to cover money owed by the other. Therefore, the allegation that the facility not refunding money after resident's death is substantiated.
Regarding the facility not giving copies of paperwork for resident R! and R2 to the POA, Ms. Salcedo admitted that she had not given copies to the family at placement; and had not given copies to them at the time of the investigation. Therefore, the allegation is substantiated. The following deficiencies are cited as per Title 22 Regulations and the Health and Safety Code. Exit interview conducted, Appeal Rights provided. This meeting was held telephonically due to concerns realted to COVID-19. A copy of these documents will be e-mailed to facility for signatures, returned, and hard copy kept in CCL file.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 208-7709
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2021
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 2
Control Number 27-AS-20200506145333
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: COLLEGE WAY RESIDENTIAL CARE
FACILITY NUMBER: 315001800
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/09/2021
Section Cited
HSC
1569.652
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Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds. (a) A residential care facility for the elderly shall not require advance notice for terminating an admission agreement upon the death of
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The facility cannot withhold refund due a resident's responsible party after the death of the resident and removal of belongings. The facility agreed to refund the remainder of the rent for R1. Refund was made to the responsible party. POC complete.
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a resident. No fees shall accrue once all personal property belonging to the deceased resident is removed from the living unit. This requirement was not met as evidenced by: the facility did not refund money owed to the resp. party for R1 after his death and removal of his belongings from the facility.
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Type B
04/09/2021
Section Cited
CCR
87507(e)
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he licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification. The licensee shall provide
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The facility shall follow regulations related to providing documentation to repsonsible parties. Facility provided refund and RP did not pursue documentation request at this time.

POC complete
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additional copies to the resident or resident’s representative upon request. This rquirement was not met as evidenced by: the facllity did not provide a copy of the Admission Agreement for R1 and R2 to the responsible party upon admission or upon request.
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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: Todd TryonTELEPHONE: (916) 208-7709
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2