347005677-9-1-2021-27-AS-KHOS-C6MP9E-20210907110702

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005677
Report Date: 09/01/2021
Date Signed: 09/01/2021 11:03:52 AM

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
10/09/2020 and conducted by Evaluator Konnor Leitzell

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20201009095113

FACILITY NAME:	LOVE AND DIVINE HOME CARE		FACILITY NUMBER:	347005677
ADMINISTRATOR:	IVANCICH, LARRY		FACILITY TYPE:	740
ADDRESS:	303 OAK CANYON WAY		TELEPHONE:	(916) 932-4883
CITY:	FOLSOM	STATE: CA	ZIP CODE:	95630
CAPACITY:	0	CENSUS: 0	DATE:	09/01/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Larry Ivancich		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Resident was illegally evicted
Facility failed to follow admission agreement
Personal Rights Violation

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Konnor Leitzell is providing findings for a complaint Community Care Licensing (CCL) received on 10/9/2020 which alleged the following, “Resident was illegally evicted”; “Facility failed to follow admission agreement”; “Personal Rights Violation” via mail due to facility being closed. LPA attempted to make contact with Larry Ivancich (Licensee) via telephone to discussed the complaint findings, but was unsuccessful. Complaint findings were sent certified mail, with two copies, one to be returned to CCL for facility file.

Throughout the course of the investigation, CCL conducted interviews and reviewed documents. Interviews were conducted with Administrator, staff, along with R1’s Responsible Party (RP). Through interviews conducted, CCL was able to determine that although facility requested R1 to sign a change of rate agreement prior to returning from the Hospital, it was ultimately R1’s RP that removed R1’s belongings from the facility.

CONT LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor Leitzell	TELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021

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-20201009095113

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: LOVE AND DIVINE HOME CARE	FACILITY NUMBER: 347005677
	VISIT DATE: 09/01/2021

NARRATIVE

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Through interviews conducted and documents reviewed, it was noted the R1 was expecting a lump sum of money to be paid in the coming years resulting from a lawsuit. Through interviews conducted, facility had requested R1 to sign an agreement stating they would continue to pay a reduction in rent, but pay a lump sum of money when the lawsuit was settled. No document was drafted or presented to R1’s RP. CCL was unable to obtain an admission agreement from either the RP nor facility after multiple request.

Through interviews conducted and documents reviewed; CCL finds the allegation of , “Resident was illegally evicted”; “Facility failed to follow admission agreement”; “Personal Rights Violation to be UNSUBSTANTIATED. A finding that the allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

LPA to send two copies of report by certified mail. LPA informed Larry Ivancich to sign and return one copy by COB 9/4/2021.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor Leitzell	TELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021

LIC9099 (FAS) - (06/04)

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