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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336425954
Report Date: 03/17/2025
Date Signed: 03/17/2025 03:20:04 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/10/2025 and conducted by Evaluator Seo Jeon
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20250310145715
FACILITY NAME:CARMIE CARES HOME FOR THE ELDERLY 1FACILITY NUMBER:
336425954
ADMINISTRATOR:JAY SESEFACILITY TYPE:
740
ADDRESS:32220 SHIFTING SANDS TRAILTELEPHONE:
(760) 656-1177
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY:6CENSUS: 4DATE:
03/17/2025
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Jay Sese, LicenseeTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Staff did not refund authorized representative after resident's death
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced complaint visit to the facility to investigate the above allegation and met with Jay Sese, Licensee, informing them of the purpose of the visit. During this investigation, LPA conducted interview with staff and obtained supportive documentation to assist in determining the findings of the noted allegation.

On March 10, 2025, Community Care Licensing (CCLD) received a complaint report alleging that staff did not refund authorized representative after resident's death.

LPA's investigation involved a comprehensive review of Resident #1's (R1) records and interviews with staff. The records review included R1’s physician’s report, admission agreement, and Licensee's record of refund checks issued.

Continued on LIC9099-C....
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2025
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 3
Control Number 18-AS-20250310145715
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CARMIE CARES HOME FOR THE ELDERLY 1
FACILITY NUMBER: 336425954
VISIT DATE: 03/17/2025
NARRATIVE
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LPA's record review revealed R1 passed away on 11-28-2024. R1's responsible person paid December 2024 rent on 11-25-2024. R1's responsible person vacated the room on 12-3-2024 by removing all personal properties. Licensee owes December rent to R1's responsible person.

LPA's review of payment record revealed the Licensee issued 2 checks in equal amounts payable to R1's responsible person on 3-16-2025. Each check shows 50% of refund due. Total amount of the 2 checks equal to full refund due the R1's responsible person.

Based on interviews and records review, staff did not refund authorized representative after resident's death is substantiated.

The preponderance of the evidence standard has been met; therefore, the above allegation is found to be substantiated.

An exit interview was conducted, and a copy of this report was provided along with copies of LIC9099-D and appeal rights.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20250310145715
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CARMIE CARES HOME FOR THE ELDERLY 1
FACILITY NUMBER: 336425954
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/28/2025
Section Cited
HSC
1569.652(c)
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Termination of admission agreement upon death of resident (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed ..... to the resident’s estate, within 15 days after the personal property is removed.
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Licensee provided 2 check stubs showing full refund amount of $2900 payble to R1's responsible party. The checks were mailed on 3-16-2025. Licensee will forward receipt of refund from R1's responsible party by 3-28-2025.
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Based on interviews and records review, the facility did not issue a full refund to the R1's responsible party within the required time frame. This poses a potential health, safety or 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.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3