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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002876
Report Date: 04/11/2024
Date Signed: 04/11/2024 01:54:25 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/05/2024 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20240405111746
FACILITY NAME:GOLDEN MOMENTS CARE HOME WINDING WAYFACILITY NUMBER:
345002876
ADMINISTRATOR:DAHLEY, DALEEFACILITY TYPE:
740
ADDRESS:4316 ILLINOIS AVENUETELEPHONE:
(916) 474-4678
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 4DATE:
04/11/2024
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Mark Graham, Facility OwnerTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Facility did not issue a refund
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Facility Owner, Mark Graham, to open a complaint into the allegation listed above.

During today's visit, LPA interviewed Facility Owner. Facility Owner stated that resident (R1) was a prospective resident, that they chose not to move into the facility after paying a preadmission fee, and a written disclousure regarding refunds for preadmission fees was not given to R1's respresentative.

Based on interviews conducted, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page.

Exit interview was conducted with Facility Owner. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
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 59-AS-20240405111746
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLDEN MOMENTS CARE HOME WINDING WAY
FACILITY NUMBER: 345002876
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/03/2024
Section Cited
CCR
87507(g)(5)(E)1.b.
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87507 Admission Agreements (g) Admission agreements shall specify the following: (5) Refund conditions. (E) Preadmission fees shall be refunded according to the following conditions: 1. A 100 percent refund of a preadmission fee shall be provided to an applicant or the applicant’s representative if: b. The licensee fails to provide full written disclosure of preadmission fee charges and refund conditions. This requirement is not met as evidenced by:
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Facility will issue a full refund for preadmission fee to R1's respresentative by POC due date of 5/3/2024.
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Based on interviews conducted, the facility did not issue a refund to R1's representative for a preadmission fee after R1's representative chose not to move R1 into the facility, which poses a potential health, safety, and personal rights violation to the 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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
LIC9099 (FAS) - (06/04)
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