347005251-3-3-2021-27-AS-MSEY-BYSVX6-20210304154859

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005251
Report Date: 03/03/2021
Date Signed: 03/03/2021 01:55:45 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
09/24/2020 and conducted by Evaluator Melana Llopis

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200924112354

FACILITY NAME:	ATRIA CARMICHAEL OAKS		FACILITY NUMBER:	347005251
ADMINISTRATOR:	HAGEN, KIMBERLY		FACILITY TYPE:	740
ADDRESS:	8350 FAIR OAKS BLVD		TELEPHONE:	(916) 944-2323
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	95	CENSUS: 157	DATE:	03/03/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Business Director, Danielle Kocsis		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility failed to provide a refund.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melana Llopis contacted the facility unannounced via telephone on 03/03/2021 due to COVID-19 and pre-cautionary measures. LPA spoke with Business Director, Danielle Kocsis due to the Administrator's absence and explained the purpose of the call.

Throughout the course of the investigation LPA Llopis conducted interviews and reviewed documents pertinent to the investigation. The complaint alleged that the facility did not provide a refund for R1.

The results are as follows:

***Continuation on LIC9099-C***

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2021

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-20200924112354

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: ATRIA CARMICHAEL OAKS	FACILITY NUMBER: 347005251
	VISIT DATE: 03/03/2021

NARRATIVE

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On 08/31/2017, resident (R1) was admitted into the facility. Admission agreement dated 08/31/2017 indicates R1 reviewed documentation and signed in agreement. On 09/04/2020 R1 passed away. On 09/05/2020, R1's family collected their belongings and removed R1's items from the facility. Billing records reviewed show on 10/01/2020 R1 was charged a total amount of $6211.00 for the full month of September 2020. According to records reviewed, the correct pro-rated amount for R1's care in September 2020 is $5190.01. The facility admitted they did not issue a refund to R1 within fifteen (15) days as required. The facility stated they were in process of issuing R1 their refund for the following dates: 09/05/2020 - 09/30/2020. On 10/05/2020 R1 was issued a refund.

Based on records reviewed and interviews conducted, LPA finds the allegation: to be SUBSTANTIATED, meaning that the allegation is valid because the preponderance of the evidence standard has been met.

The following deficiency is being cited on LIC9099-D.

Exit interview conducted via telephone, copy of report provided to facility, appeal rights provided as well as a copy of Health and Safety Code 1569.652. Facility will print, sign and send a signed copy of complaint report to LPA.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2020

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20200924112354

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: ATRIA CARMICHAEL OAKS	FACILITY NUMBER: 347005251
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/03/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/17/2021 Section Cited HSC 1569.652(c)	1 2 3 4 5 6 7	Health and Safety Code section 1569.652 provides in part: (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the ... entity contractually responsible for the fees ...within 15 days after the personal property is removed.	1 2 3 4 5 6 7	Licensee refunded R1 on 10/05/2020. Licensee agrees to review health and safety code 1569.652 in its entirety and provide signed documentation confirming the health and safety code has been reviewed. Signed documentation to be provided to CCL by the POC date, 03/17/2021.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Licensee did not ensure R1's responsible party received their refund within 15 days of R1's belongings being moved out from the facility. This posed a potential personal rights risk to resident in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2021

LIC9099 (FAS) - (06/04)

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