342700828-5-13-2021-27-AS-CACL-C36KQ7-20210519080552

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700828
Report Date: 05/13/2021
Date Signed: 05/13/2021 04:54:59 PM

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
11/05/2020 and conducted by Evaluator Anthony Tuck

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20201105085149

FACILITY NAME:	LOVE AND SERENITY OF ELK GROVE III		FACILITY NUMBER:	342700828
ADMINISTRATOR:	CASTRO, BIANCA		FACILITY TYPE:	740
ADDRESS:	9442 MAZATLAN WAY		TELEPHONE:	(916) 585-5483
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY:	6	CENSUS:	DATE:	05/13/2021
		UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Administrator Bianca Castro		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Facility is overcharging resident for services.

Facility refused to transport resident to their medical appointments.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Anthony Tuck contacted the facility on 05/13/2021 via telephone due to COVID 19 safety precautions. LPA spoke with Administrator Bianca Castro. LPA explained reason for the call to review and deliver the findings of the complaint.

The initial 10-day visit was conducted on 11/13/2020. LPA conducted an interview with R1 and the administrator, reviewed copies of the admission agreement and the physician report for R1. The first allegation was that the facility is overcharging the resident for services. LPA learned that the resident is not responsible for paying the monthly services for the facility based upon review of the admissions agreement. The second allegation is the facility refused to transport resident to their medical appointments. LPA learned that transportation was not refused. LPA learned that the medical appointments had been rescheduled based on dates that transportation provided by the administrator were available. LPA also learned that all transportation fees were waived for R1 based on the financial circumstances for R1.
Continued on LIC 9099C...

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (209) 242-5200
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20201105085149

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: LOVE AND SERENITY OF ELK GROVE III	FACILITY NUMBER: 342700828
	VISIT DATE: 05/13/2021

NARRATIVE

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This agency has investigated the allegations listed above. We have found that the complaint was unfounded,
meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have
therefore dismissed the complaint. Exit interview was conducted with Administrator. Copy of the report sent to
Administrator via e-mail with a "read receipt" to verify the LIC 9099 was received. Administrator is to print out
the report, sign it, and email or fax a signed copy to LPA at 916-263-4744.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (209) 242-5200
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021

LIC9099 (FAS) - (06/04)

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