345002868-12-14-2022-25-AS-APEZ-CMBME5-20221221083207

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345002868
Report Date: 12/12/2022
Date Signed: 12/14/2022 04:49:37 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 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
12/07/2022 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 25-AS-20221207155201

FACILITY NAME:	HAZEL HOME FOR SENIORS		FACILITY NUMBER:	345002868
ADMINISTRATOR:	GRANT, CLEOPATRA		FACILITY TYPE:	740
ADDRESS:	4919 HAZEL AVENUE		TELEPHONE:	(831) 334-1223
CITY:	FAIR OAKS	STATE: CA	ZIP CODE:	95628
CAPACITY:	6	CENSUS: 3	DATE:	12/12/2022
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Cleopatra Grant, Licensee		TIME COMPLETED:	12:40 PM

ALLEGATION(S):

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Unlawful Rent Increase

Facility did not provide Invoice as stated on Admission Agreement

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Licensee, Cleopatra Grant, to open a complaint investigation into the allegations listed above. Licensee gave permission to have caregiver, Dian Evering, sign report. LPA wore a surgical mask. Facility staff wore masks while on the premises.

During today’s visit, LPA conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Unlawful Rent Increase

** Report continued on 9099-C **

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022

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 25-AS-20221207155201

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: HAZEL HOME FOR SENIORS	FACILITY NUMBER: 345002868
	VISIT DATE: 12/12/2022

NARRATIVE

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Review of resident (R1's) file indicated that a rent increase was established via Admission Agreement signed on 12/04/2022, with a $500 increase from previous Admission Agreement signed on 7/01/2020. During inspection conducted on 12/12/2022, LPA requested a copy of the written notice used in the rate increase for R1. Facility did not provide a written notice to LPA during inspection.

Interviews conducted with Licensee and facility owner indicated that the rate increase was due to a change in level of care. An LIC 602 was completed on 4/20/2022 for R1 to identify changes in care. Interviews with Licensee and facility owner indicated that no written notice was provided to R1's authorized representative prior to the change in rate or the signing of R1's Admission Agreement on 12/04/2022.

Allegation: Facility did not provide invoice as stated on Admission Agreement

R1's Admission Agreement (signed 7/01/2020) states "the billing and payment policies and procedures are: An invoice will be given to the resident and/or responsible party on the first of each month." R1's Admission Agreement (signed 12/04/2022) states "the billing and payment policies and procedures are: invoice will be sent to resident responsible part." During inspection conducted on 12/12/2022, LPA requested a copy of the invoices for R1's rent sent to R1's authorized representative.

Interviews conducted with Licensee and facility owner indicated that an invoice for some months (exact months were not identified) were not provided to R1's authorized representative. Facility did not provide any invoice copies to LPA during 12/12/2022 inspection.

Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page.

Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. Administrator's signature on these forms acknowledges receipt of these documents.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20221207155201

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: HAZEL HOME FOR SENIORS	FACILITY NUMBER: 345002868
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/12/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/27/2022 Section Cited HSC 1569.657(a)	1 2 3 4 5 6 7	§1569.657 Rate increase due to change in level of resident care; notice (a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility will send a written notice to R1's authorized representative indicating additional services provided. Facility will provide a copy of the written notice to LPA by POC due date of 12/27/2022.
	8 9 10 11 12 13 14	Based on interviews conducted and records reviewed, the facility did not ensure to send a written notice to R1's authorized representative regarding a rate increase due to a change in the level of R1's care, which poses a potential health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14
Type B 12/27/2022 Section Cited CCR 87507(f)	1 2 3 4 5 6 7	87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility will send any missing invoices to R1's authorized representative. Facility will provide proof that the invoices were sent to R1's authorized representative to LPA by POC due date of 12/27/2022.
	8 9 10 11 12 13 14	Based on interviews conducted and records reviewed, the facility did not ensure to send an invoice for R1's rent every month to R1's authorized representative in agreement with R1's Admission Agreement, which poses a potential health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14

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: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022

LIC9099 (FAS) - (06/04)

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