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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700645
Report Date: 03/16/2022
Date Signed: 03/16/2022 12:17:38 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
03/10/2022 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 25-AS-20220310092832
FACILITY NAME:ROBERT CREEK VILLA IIFACILITY NUMBER:
342700645
ADMINISTRATOR:MARICAR R KINGFACILITY TYPE:
740
ADDRESS:8138 ROBERT CREEK CT.TELEPHONE:
(916) 276-2356
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 4DATE:
03/16/2022
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Maricar R King, AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Illegal eviction
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct an annual inspection. LPA met with Administrator Maricar King during today's inspection. LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Masks.
LPA investigated allegation "Illegal eviction" and interviewed administrator. Administrator stated R1 was having behaviors of aggression that facility was unable to care for. Administrator stated they verbally informed the family that new placement was needed but a written 30 day notice was not given to R1's representative. In March 2022, R1 was sent out to the emergency department. R1 needed to be discharged however administrator refused for R1 to be returned to facility due to R1's behaviors. Due to information gathered, Administrator did not provide R1's representative with a written 30 day eviction notice which resulted in an illegal eviction.
As a result of this investigation, LPA finds allegations to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.
Deficiencies cited on 9099-D. Exit interview conducted.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
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 25-AS-20220310092832
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: ROBERT CREEK VILLA II
FACILITY NUMBER: 342700645
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/25/2022
Section Cited
CCR
87224(a)
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87224(a) Eviction Procedures. The licensee may, upon thirty (30) days written notice to the resident, evict the resident for nonpayment of the rate for basic services, failure to comply with state or local law, failure to comply with the general policies of the facility, development of a need not previously identified, and/or a change of use of the facility.
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Administrator to review regulation 87224 and submit to CCL a letter of understanding of the eviction process. Letter of understanding due by 3/25/22.
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This requirement is not met as evidenced by: Based on interviews the licensee did not provide R1 and R1's representative with a written 30 day notice which poses a potential health and personal 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) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
LIC9099 (FAS) - (06/04)
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