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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347003843
Report Date: 08/17/2022
Date Signed: 08/29/2022 03:50:49 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, 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
08/04/2022 and conducted by Evaluator Kevin Mknelly
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20220804165808
FACILITY NAME:NORTH AVENUE VILLAFACILITY NUMBER:
347003843
ADMINISTRATOR:ADRIAN BERCIFACILITY TYPE:
740
ADDRESS:5216 NORTH AVENUETELEPHONE:
(916) 705-3729
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: DATE:
08/17/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:CaregiverTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Residents did not receive a 60 day notice.
INVESTIGATION FINDINGS:
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 ** Amended** Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 8/17/22 to deliver complaint findings. LPA met with caregiver and explained the purpose of the visit. Prior to initiating the complaint visit, LPA completed the department's required COVID-19 testing and screening protocols. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by facility staff upon entering the facility. LPA spoke with Karl and Devi Ramos by phone
The department reviewed client/resident records and conducted extensive interviews.
The department finds that the allegations cited above are substantiated. Interviews and copy of notice given to residents found that residents were not provided 60-day written notices of a chnge of ownership as defined in 87224(a)(5)(A)(1) Eviction Procedures.
As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6.
Report reviewed with . Copy of this report and appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022
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 2
Control Number 25-AS-20220804165808
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: NORTH AVENUE VILLA
FACILITY NUMBER: 347003843
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/24/2022
Section Cited
CCR
87224(a)(5)(A)(1)
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Eviction notices-(a)(5)(A) The licensee may, upon no less than sixty (60) days written notice, evict a resident due to change of use of the facility.1. In addition to written notice to quit requirements specified in Section 87224(d), written notice to evict due to change of use of the facility shall be made to the resident or the resident’s responsible person and shall include all requirements specified
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Licnesee will submit correct 60-day notices to residentsare and copy set to CCL by 8/24/22.
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the facility shall be made to the resident or the resident’s responsible person and shall include all requirements specified .
This requiremtn was not met for 5 of 5 residents. This potentially violated their personal rights.
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022
LIC9099 (FAS) - (06/04)
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