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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 317005513
Report Date: 12/07/2023
Date Signed: 12/07/2023 03:25:01 PM

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
11/27/2023 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 59-AS-20231127153107
FACILITY NAME:STERLING COURT AT ROSEVILLEFACILITY NUMBER:
317005513
ADMINISTRATOR:DEBRA DUVALFACILITY TYPE:
740
ADDRESS:100 STERLING CTTELEPHONE:
(916) 786-7200
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:128CENSUS: 74DATE:
12/07/2023
UNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Debra Duval, Administrator TIME COMPLETED:
03:35 PM
ALLEGATION(S):
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Facility did not refund resident's responsible party.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint findings. LPA met with Debra Duval during today's inspection.
LPA reviewed R1 admission agreement, billing statements, and other documentation. Admission agreement indicates after the death of a resident within fifteen days after property is removed from apartment, estate, or other person or entity will receive a refund of any fees paid in advance. LPA was able to determine R1 passed in October 2023 and a refund was not issued until December 2023. In addition, Health and Safety Code §1569.652 states facilities are required to refund responsible party within 15 days of the death of a resident and once their personal belongings have been removed. Due to the information gathered, LPA finds allegation to be SUBSTANTIATED. Deficiencies cited on 9099-D. Exit interview conducted 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: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023
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 2
Control Number 59-AS-20231127153107
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: STERLING COURT AT ROSEVILLE
FACILITY NUMBER: 317005513
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2023
Section Cited
HSC
1569.652(c)
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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
(c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed.
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Administrator agrees to meet with R1's responsible party to review refund amount. Once meeting has taken place Administrator to send LPA the refund amount given to R1's responsible party.
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Based on record review facility did not refund R1's repsonsible party withing 15 days which poses a potential personal rights risk to residents in care.
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POC due by 12/29/23.
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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: 12/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023
LIC9099 (FAS) - (06/04)
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