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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700651
Report Date: 12/20/2022
Date Signed: 12/21/2022 03:41:26 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/02/2021 and conducted by Evaluator Victoria Brown
COMPLAINT CONTROL NUMBER: 27-AS-20210702131448
FACILITY NAME:PADUA ASSISTED LIVINGFACILITY NUMBER:
342700651
ADMINISTRATOR:PADUA, NICHOLASFACILITY TYPE:
740
ADDRESS:7019 MCGILL COURTTELEPHONE:
(916) 647-3483
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:6CENSUS: 2DATE:
12/20/2022
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Angelita PaduaTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff mishandled resident's personal funds while in care
Staff mislead resident to sign legal documents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Victoria Brown conducted a meeting via Phone call on 12/20/22 at 3pm with Angelita Dayoan to discuss revision of the complaint allegations.

In regard to the first allegation, “Staff mishandled resident's personal funds while in care”, the Audit deemed the allegation to be unfounded. However, a further review of the documents such as the Trust of Resident #1 (R1) revealed that the Licensee became Trustee over R1 and is listed as heir to 50% of assets (beneficiary). The agreement was entered into on 4/14/2020 and notarized on 4/25/2020.

This agreement violates Title 22 regulations 87217(d)(1-2) Safeguards for Resident Cash, Personal Property, and Valuables
…no licensee or employee of a facility shall: accept appointment as a guardian or conservator…
Substantiated
Estimated Days of Completion: 120
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022
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 3
Control Number 27-AS-20210702131448
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: PADUA ASSISTED LIVING
FACILITY NUMBER: 342700651
VISIT DATE: 12/20/2022
NARRATIVE
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In regard to the second allegation, “Staff mislead resident to sign legal documents”, A review of legal documents obtained, LPA observed on Appraisal/Needs and Services Plan (LIC625) dated 9/3/2019 R1 was assessed as having cognitive disorder, able to follow instructions and cannot function without help. LPA also observed on R1’s physician report (LIC602A) dated 8/28/2019 which indicates a primary diagnosis of cognitive disorder and Mild Cognitive Impairment with mental condition of confused and disoriented aggressive and wandering. It also mentions that R1 is not able to manage own cash resources or medications. R1’s Preplacement Appraisal Information (LIC 603) dated 11/1/2019 indicates R1 is forgetful. LPA observed that Licensee Angelita Dayoan is named as the Co-alternate for Durable Power Attorney for Health Care Decisions and is mentioned on R1’s Last Will and Testament.

This agreement violates Title 22 regulations 87217(d)(3-4) Safeguards for Resident Cash, Personal Property, and Valuables
…no licensee or employee of a facility shall: accept appointment…and/or estate of any resident; …general or special power of attorney…become substitute payee for any payments made to any persons…

Based on observations and the review of documentation submitted the preponderance of evidence standards has been met; therefore, the above allegation(s) is found to be SUBSTANTIATED. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 9099D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20210702131448
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PADUA ASSISTED LIVING
FACILITY NUMBER: 342700651
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/21/2022
Section Cited
CCR
87217(d)(1-2)
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Safeguards for Resident Cash, Personal Property, and Valuables
…no licensee or employee of a facility shall: accept appointment as a guardian or conservator…
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Licensee shall keep all receipts for any monies obtained for the licensed facility for review by CCL upon request. A letter of agreement shall be submitted to CCL. To be faxed by POC due date.
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This requirement is not met as evidenced by: The Licensee was handling residents monies without having on file an LIC400/LIC402
Based on Licensee did not ensure R1’s Cash, Personal Property, and Valuables were safeguarded by assisting to write checks and having the resident sign them and she stated she did not have these forms on file with CCL.
This posed an immediate health and safety risk to residents in care.
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Type A
12/21/2022
Section Cited
CCR
87217(d)(3-4)
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Safeguards for Resident Cash, Personal Property, and Valuables
…no licensee or employee of a facility shall: accept appointment…and/or estate of any resident; …general or special power of attorney…become substitute payee for any payments made to any persons…
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Licensee shall write a statement of understanding and Title 22 regulations shall be followed at all times. A letter of agreement shall be submitted to CCL. To be faxed by POC due date.
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This requirement is not met as evidenced by: Legal documents provided
Based on interviews and records review, the licensee did not safeguard R1’s assets by becoming the trustee and 50% heir.
This posed an immediate health and safety 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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3