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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374601276
Report Date: 03/23/2023
Date Signed: 03/24/2023 08:45:41 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/10/2021 and conducted by Evaluator Debbie Correia
COMPLAINT CONTROL NUMBER: 08-AS-20210210122004
FACILITY NAME:ANGEL'S GUEST HOME #1FACILITY NUMBER:
374601276
ADMINISTRATOR:JENKINS, PATRICIAFACILITY TYPE:
740
ADDRESS:9208 BELLAGIO RDTELEPHONE:
(619) 258-2013
CITY:SANTEESTATE: CAZIP CODE:
92071
CAPACITY:6CENSUS: 6DATE:
03/23/2023
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Licensee McEvoyTIME COMPLETED:
11:40 AM
ALLEGATION(S):
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Staff failed to issue refund.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to deliver findings regarding the above listed complaint allegation. LPAs identified themsrlves to Licensee McEvoy to whom was explained the purpose of the visit.

The department’s investigation consisted of staff and outside source interviews.

It was alleged facility staff did not issue a reimbursement upon Resident’s1 (R1) death. An Outside Source1 (OS1) (See LIC 811 for confidential names list) interview revealed R1 passed away on July 10, 2020, and as of March 4, 2021, the Licensee had not issued a full reimbursement to R1's Responsible Party (RP). The interview conducted with OS1 also revealed R1's RP agreed with the Licensee to accept installment payments of $500. OS1 revealed at the time the complaint was filed, on February 2, 2021, the RP had only received one payment of $500.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
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 08-AS-20210210122004
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ANGEL'S GUEST HOME #1
FACILITY NUMBER: 374601276
VISIT DATE: 03/23/2023
NARRATIVE
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An interview with an additional Outside Source2 (OS2) corroborated the RP agreed to receive installments of $500 from the Licensee and had only received one payment approximately 8 months after R1's passing. The interview with OS2 also revealed the Licensee eventually provided a full reimbursement, of borrowed money, after the filing of this complaint. Licensee did not provide facility records for this complaint.

Based on LPA’s investigation, the above allegation is determined to be substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. A deficiency is cited per Title 22 of the California Code of Regulations and is listed on form LIC 9099-D.

LPA Correia conducted an exit interview with Licensee McEvoy. At the time of the exit interview with Licensee McEvoy was given a copy of this report, LIC 9099, LIC 9099-D, and Licensee Rights (LIC9058 01-2016), and signature on this report acknowledges receipt of the rights.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20210210122004
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ANGEL'S GUEST HOME #1
FACILITY NUMBER: 374601276
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/21/2023
Section Cited
HSC
1569.652
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Termination... upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds. A refund of any fees...covering the time after the resident’s... property has been removed ...shall be issued...within 15 days...
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Licensee agreed to conduct a cost analysis utilizing CCL's LIC 401 Monthly Operating Statement form. Licensee also agreed to attend, including facility Administrator, CCL approved vendorized training regarding refunds/reimbursements per Title 22 mandate.
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Based on interviews the Licensee did not issue a refund upon the death of R1. This poses a potential personal right violation to 1 out of 6 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: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3