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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005580
Report Date: 11/13/2020
Date Signed: 11/13/2020 03:27:38 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
07/10/2020 and conducted by Evaluator Melana Llopis
COMPLAINT CONTROL NUMBER: 27-AS-20200710125044
FACILITY NAME:MOUNTAIN MANOR SENIOR RESIDENCEFACILITY NUMBER:
347005580
ADMINISTRATOR:JAMES JORDANFACILITY TYPE:
740
ADDRESS:6101 FAIR OAKS BLVDTELEPHONE:
(415) 250-2721
CITY:FAIR OAKSSTATE: CAZIP CODE:
95608
CAPACITY:33CENSUS: 16DATE:
11/13/2020
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Administrator, Darrell PriceTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Improper rent increase
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Llopis contacted the facility via telephone due to COVID-19 and pre-cautionary measures on 11/13/2020. LPA spoke with Administrator, Darrell Price and explained the purpose of the visit was to deliver findings for complaint 27-AS-20200710125044 received on 07/10/2020.

Throughout the investigation the Department conducted interviews with staff, key witness and reviewed documentation pertinent to the investigation.

The results are as follows:

Allegation: Improper rent increase

***Continuation on 9099-C***
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Melana LlopisTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020
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 27-AS-20200710125044
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: MOUNTAIN MANOR SENIOR RESIDENCE
FACILITY NUMBER: 347005580
VISIT DATE: 11/13/2020
NARRATIVE
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On 04/15/2019, resident (R1) moved into the facility. R1's admission agreement shows R1 agreed to pay a monthly rental cost of $1,058.37. In the admission agreement, the facility agreed to send a written notice to R1 and their responsible party sixty (60) days in advance if an increase in rent would occur, along with a reason for increase. Records reviewed show on 02/01/2020 R1's rent increased to $1069.37. Interview with Administrator revealed the facility did not send out a sixty (60) day written notice prior to applying an increase to R1's rent.

Based on the information above, the Department finds the allegation to be SUBSTANTIATED, meaning the preponderance of evidence standard has been met

A deficiency is being cited on 9099-D, PER CALIFORNIA CODE OF REGULATIONS, Title 22, Division 6.

Exit interview conducted, appeal rights and copy of report provided. Facility will print, sign, and send a signed copy to CCL.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Melana LlopisTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20200710125044
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: MOUNTAIN MANOR SENIOR RESIDENCE
FACILITY NUMBER: 347005580
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/20/2020
Section Cited
HSC
1569.655
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Increase in fee rates for elderly residents; 60 days’ written notice stating amount of and reasons for increase; application of section
(a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 60 days' prior written notice to the residents or the residents' representatives setting forth the amount of the increase, the reason for the increase, and a general description of the additional costs, except for an increase in the rate due to a change in the level of care of the resident.
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Licensee agrees to provide CCL by the POC date with a plan and procedures on how all future rent increases will be properly issued.
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This requirement was not met as evidenced by: Based on interviews and records reviewed, CCL was able to determine licensee increased resident rate without providing responsible party with a written notice, which poses a potential health risk to 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: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Melana LlopisTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020
LIC9099 (FAS) - (06/04)
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