347002889-9-15-2023-59-AS-KHOS-CVTKAP-20230919074416

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347002889
Report Date: 09/15/2023
Date Signed: 09/15/2023 04:32:02 PM

Unfounded

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
09/13/2023 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20230913133833

FACILITY NAME:	GOLDEN CREST CARE CENTER		FACILITY NUMBER:	347002889
ADMINISTRATOR:	VICTOR BURACHEK		FACILITY TYPE:	740
ADDRESS:	8120 PATTON AVENUE		TELEPHONE:	(916) 725-6766
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95610
CAPACITY:	6	CENSUS: 4	DATE:	09/15/2023
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Victor Burachek, Administrator		TIME COMPLETED:	04:35 PM

ALLEGATION(S):

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Staff did not issue a refund to responsible party.
Staff did not provide responsible party an admissions agreement.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open a complaint received on 9/13/23. LPA met with Administrator, Victor Burachek and caregiver, Natalia Burachek and explained the purpose of the inspection. LPA observed (3) resident in the common area and (1) in his room.

During today's inspection, LPA interviewed the Administrator and observed paperwork and electronic documentation relating to the allegations. LPA interviewed a family member of resident (R1) during the course of the investigation. Resident (R1) moved to the facility on 9/7/23 and went to the hospital on 9/9/23 where he passed. Resident was under hospice care when he moved in. The Department was asked that the complaint be withdrawn on 9/14/23; however, Department policy is to investigate any and all complaints received if there are potential Title 22 violations.

The results of the investigation are as follows:
*cont on 9099C-1..

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

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 59-AS-20230913133833

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 CREST CARE CENTER	FACILITY NUMBER: 347002889
	VISIT DATE: 09/15/2023

NARRATIVE

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9099C-1... Allegation: Staff did not issue a refund to responsible party. The complaint alleges that a daily rate was not discussed and the first (30) days of rent is not refundable if a resident is on hospice.

The Administrator confirmed that it is the facility's policy that if a resident is admitted to the facility under hospice care and passes within the first (30) days, any pre-paid rent monies are non-refundable. The Administrator confirmed that this is based on the policy of "some placement agencies" and confirmed "this discussion didn't take place" with (R1s') responsible person(s); however, the agent from the placement agency agreed to not charge any fee since (R1) was only at the facility for (3) days before going to the hospital and passing on 9/9/23. The Administrator confirmed that the agent informed (R1's) representative that the same daily rate is charged if the room is occupied by the resident, and as long as the belongings remain in the room.

The Administrator stated that he advised (R1s') family after (R1) passed that there were (2) options - 1- the entire amount paid for the first month is non-refundable or 2- the facility can charge a daily rate for the days (R1) received care until his belongings were removed from the room on 9/12/23. The Administrator stated that (R1's) representative agreed to a daily rate and provided electronic documentation that a refund was sent to the responsible person on 9/12/23, after (7) days were calculated as due. (R1's) family member disputed the refund amount, stating that (6) days only should be charged, from 9/7/23 - 9/12/23. On 9/14/23, the Administrator then refunded an additional day, which (R1's) family agreed with.

LPA confirmed with a family member of (R1) that the total refund received following (R1) passing was acceptable and is not being disputed and the allegation was requested to be withdrawn.

Based on information received, LPA finds that the facility issued a refund to the responsible person within (15) days of the room being cleared of resident's belongings, per Health and Safety Code §1569.652, and finds it to be UNFOUNDED- finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis.

cont on 9099C-2...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20230913133833

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 CREST CARE CENTER	FACILITY NUMBER: 347002889
	VISIT DATE: 09/15/2023

NARRATIVE

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9099C-2.... Allegation: Staff did not provide responsible party an admissions agreement. The complaint alleges that (R1) moved to the community on 9/7/23 and a contract was not signed that day due to it taking time to draft. (R1) passed on 9/9/23 at the hospital.

The Administrator stated that when (R1) moved in on 9/7/23, it was agreed the contract would be signed the next or following day, since it was in the evening already, stating the family member was in a hurry the following day and not able to sign the agreement and then the resident was sent to the emergency room on 9/9/23 and passed.

Regulation 87507(c) reads: Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

Administrator agrees to update the paragraph in the Admission Agreement about if a resident moves in on hospice and that the first 30-days are non-refundable.

Based on information obtained, LPA finds the allegation to be UNFOUNDED- finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis.

Exit interview. Copy of report provided to the facility.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

LIC9099 (FAS) - (06/04)

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