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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 355201055
Report Date: 04/16/2022
Date Signed: 04/19/2022 10:21:18 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/15/2020 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 26-AS-20201215142944
FACILITY NAME:WHISPERING PINES INN, LLCFACILITY NUMBER:
355201055
ADMINISTRATOR:PARK,CHARLES & MAEFACILITY TYPE:
740
ADDRESS:476 LOS VIBORAS ROADTELEPHONE:
(831) 636-9620
CITY:HOLLISTERSTATE: CAZIP CODE:
95023
CAPACITY:36CENSUS: 21DATE:
04/16/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lead Caregiver Emelia Gomez TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Illegal Eviction
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility unannounced on April 16 ,2022 at 10:00 a.m. to investigate a complaint on the above allegations. LPA met with lead Caregiver Emelia Gomez and explained the purpose for today’s visit.

Regarding the allegation of Illegal Eviction. Based on LPA interviews the facility refused to accept Resident 1 back to the facility after being discharged from the hospital on 12/16/2020. The facility was responsible for Resident 1 on 12/16/2020 as he was already a resident living at the facility. The facility did illegally evict Resident 1 when they refused to allow him to return to the facility. Therefore, this allegation is SUBSTANTIATED.

The following deficiencies were cited per Title 22 Division 6. An exit interview was conducted with Lead Caregiver Emelia Gomez and a copy of this report along with appeal rights was left at the facility.





Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2022
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 26-AS-20201215142944
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: WHISPERING PINES INN, LLC
FACILITY NUMBER: 355201055
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
04/19/2022
Section Cited
CCR
87224(a)
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87224 Eviction Procedures(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5).
The following requirement has not been met as evidenced by:
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Licesnee will submit proof of regulation review and understanding to LPA by 04/19.2022 POC date.
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The Licensee failed to accept Resident 1 back into the facility after being discharged from the hospital. This is considered an illegal eviction which poses a potential health, safety or personal rights 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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2