361880939-7-30-2021-18-AS-EMAN-C67PR4-20210824113209

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880939
Report Date: 05/12/2021
Date Signed: 07/30/2021 04:03:46 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/02/2021 and conducted by Evaluator Elecia Weathersby

COMPLAINT CONTROL NUMBER: 18-AS-20210402164156

FACILITY NAME:	TLC HOME CARE		FACILITY NUMBER:	361880939
ADMINISTRATOR:	MATE, KELVIN		FACILITY TYPE:	740
ADDRESS:	30886 SUTHERLAND DRIVE		TELEPHONE:	(909) 351-6012
CITY:	REDLANDS	STATE: CA	ZIP CODE:	92373
CAPACITY:	6	CENSUS: 6	DATE:	05/12/2021
		UNANNOUNCED	TIME BEGAN:	09:14 AM
MET WITH:	Administrator, Kelvin Mate		TIME COMPLETED:	09:32 AM

ALLEGATION(S):

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Facility staff failed to provide refund to responsible party.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elecia Weathersby contacted the facility via telephone to commence a complaint investigation via telephone due to COVID-19. LPA identified herself and discussed the purpose of the call and the elements of the above allegation with Administrator Kelvin Mate @(909)351-6012.

During the course of the investigation, LPA completed a tele-inspection of the facility. In addition, LPA conducted interviews with all relevant parties. Resident 1 (R1) was admitted to the facility on 1/2/20. The allegation indicates that the licensee failed to refund the resident's estate in a timely manner after the resident passed away. LPA verified R1's date of death was 1/5/21. R1's responsible party moved R1's personal belongings out of the facility the following day on 1/6/21.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Elecia Weathersby	TELEPHONE: (951) 255-9516
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021

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 18-AS-20210402164156

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: TLC HOME CARE	FACILITY NUMBER: 361880939
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/12/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/12/2021 Section Cited HSC 1569.652(c)	1 2 3 4 5 6 7	HSC 1569.652 (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed... shall be issued to the individual... contractually responsible for the fees... within 15 days after the personal property is removed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The licensee agrees to stop the practice of no refund to hospice residents and shall issue a refund to the R1's responsible party or estate. The licensee shall submit a letter of agreement to the department by 5/12/2021.
	8 9 10 11 12 13 14	Based on interviews and file review, the licensee failed to issue a refund to the resident's estate 15 days after the resident's personal property was removed. This poses a potential health and safety risks to persons 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: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Elecia Weathersby	TELEPHONE: (951) 255-9516
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 18-AS-20210402164156

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: TLC HOME CARE	FACILITY NUMBER: 361880939
	VISIT DATE: 05/12/2021

NARRATIVE

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Per Health & Safety Code 1569.652 Since R1's personal property was removed on 1/6/2021, the licensee was required to issue the refund by 1/21/2021 (15 days after the move-out date), as R1's rent was paid through the month of January 2021. The Administrator, Kelvin Mate, confirmed that R1's estate was never issued a refund. This poses a potential financial risk.

Based on LPA's interviews and file reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Health & Safety Code, (Title 22, Division 6 & Chapter 3.2) is being cited on the attached LIC9099D.

An exit interview was conducted where this report, LIC9099D, and appeal rights were discussed and provided to the Administrator, Kelvin Mate.

A copy of this report was reviewed with and provided to the Administrator.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Elecia Weathersby	TELEPHONE: (951) 255-9516
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021

LIC9099 (FAS) - (06/04)

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