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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423521
Report Date: 10/27/2023
Date Signed: 10/27/2023 11:38:08 AM


Document Has Been Signed on 10/27/2023 11:38 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:ABBEY ELDER CARE, INC.FACILITY NUMBER:
336423521
ADMINISTRATOR:SUNDEEP RANDHAWAFACILITY TYPE:
740
ADDRESS:3412 WEXFORD CIRCLETELEPHONE:
(951) 858-8641
CITY:CORONASTATE: CAZIP CODE:
92882
CAPACITY:6CENSUS: 5DATE:
10/27/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Claudia Pinon TIME COMPLETED:
11:50 AM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to the facility for complaint control number 56-AS-20230627095436. During the complaint visit, LPA Rico completed a case management visit to cite for a deficiency found during the complaint record review.

During record review, LPA noted that facility issued a written notice less than 60 days for an increase for the years 2021,2022,2023. Licensee did not provide the written notice within 60 days. For the year 2021 the notice was given January 27,2021 and the new monthly rate began February 1, 2021. In the year 2022 the notice was given January 27, 2022, and the new monthly rate began March 1, 2022. And for the year 2023 the notice was given January 3, 2023, and the new monthly rate began February 1, 2023.

During today’s visit, one (1) deficiency was cited per Health and Safety Code Section 1569.655(a)

An exit interview was conducted, and this report was discussed and provided to Claudia Pinon, along with a copy of the appeal rights.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/27/2023 11:38 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: ABBEY ELDER CARE, INC.
FACILITY NUMBER: 336423521

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/03/2023
Section Cited
HSC
1569.655(a)

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1569.655(a)Increase in fee rates for elderly residents; 60 days’ written notice stating amount of and reasons for increase; (a) If a licensee increases..the licensee shall provide no less than 60 days' prior written notice to the resident..
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Licensee will send LPA confirmation they have read the regulation and will provide no less than 60 days written notice to residents or resident's representativies when increasing prices.
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 Based on record review, the licensee did not comply with the section cited above by providing written notice less than 60 days which poses a potential health, safety or personal rights risk to persons in care.
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POC due date 11/3/2023

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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: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023
LIC809 (FAS) - (06/04)
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