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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366427079
Report Date: 08/19/2020
Date Signed: 08/19/2020 03:22:39 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
08/14/2020 and conducted by Evaluator Natalie Gayoso
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200814130416
FACILITY NAME:LEGACY HOUSEFACILITY NUMBER:
366427079
ADMINISTRATOR:CHALIFOUX, LYNNFACILITY TYPE:
740
ADDRESS:1791 N SECOND AVETELEPHONE:
(909) 762-9986
CITY:UPLANDSTATE: CAZIP CODE:
91784
CAPACITY:6CENSUS: 3DATE:
08/19/2020
UNANNOUNCEDTIME BEGAN:
11:06 AM
MET WITH:Lynn Chalifoux - Administrator TIME COMPLETED:
03:18 PM
ALLEGATION(S):
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Facility is not providing appropriate refund
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Natalie Gayoso contacted the facility via telephone to commence a complaint investigation due to COVID-19. LPA identified herself and discussed the purpose of the call and the elements of the allegations with Administrator, Lynn Chalifoux
The allegation indicated that facility is not providing appropriate refund. Reporting Party alleged prorated refund was not provided following an eviction of R1. According to the Administrator, R1’s Responsible Party was made aware at Admission that a refund would only be provided upon death of the resident. LPA reviewed admissions agreement and observed that the agreement does not provide additional reasons for which a refund is deemed.
Based on the information obtained, the allegation is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.


Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie GayosoTELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2020
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 2
Control Number 18-AS-20200814130416
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: LEGACY HOUSE
FACILITY NUMBER: 366427079
VISIT DATE: 08/19/2020
NARRATIVE
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No deficiencies were cited during this visit. An exit interview was conducted with the administrator via telephone and a copy of this report was provided to the administrator via email. Report with facility signature was obtained.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie GayosoTELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2