374603155-11-15-2021-08-AS-SJAB-C9YQ2R-20211223104733

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603155
Report Date: 11/15/2021
Date Signed: 11/15/2021 04:56:11 PM

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
09/13/2021 and conducted by Evaluator Kristina Ryan

COMPLAINT CONTROL NUMBER: 08-AS-20210913142247

FACILITY NAME:	LILAC CHATEAU 1		FACILITY NUMBER:	374603155
ADMINISTRATOR:	WITHERS, KIMBERLY		FACILITY TYPE:	740
ADDRESS:	9718 EUCALYPTUS COURT		TELEPHONE:	(619) 312-1494
CITY:	SANTEE	STATE: CA	ZIP CODE:	92071
CAPACITY:	6	CENSUS: 4	DATE:	11/15/2021
		UNANNOUNCED	TIME BEGAN:	10:19 AM
MET WITH:	Licensee, Kimberly Withers		TIME COMPLETED:	11:58 AM

ALLEGATION(S):

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Facility did not refund the balance of rent upon resident death.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Kristina Ryan, conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA was allowed entry into the facility after identifying herself and stating the purpose of the visit to Caregiver, Victoria Sumalinog. LPA met with Licensee, Kimberly Withers

The Department’s investigation consisted of a review of facility administrative and care records. It also involved interviews with facility staff, and outside sources.

The Department received a complaint on September 13, 2021, alleging that the facility did not issue a refund of the balance of rent upon a resident death. Interviews with the Licensee and with outside sources revealed that resident 1 (R1) was a resident at the facility and their legally responsible person signed an admission agreement on August 30, 2021. At the time of admission, R1 was receiving palliative care services.

[CONTINUED ON LIC 9099-C, 1 of 3]

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina Ryan	TELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021

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 4

Control Number 08-AS-20210913142247

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: LILAC CHATEAU 1	FACILITY NUMBER: 374603155
	VISIT DATE: 11/15/2021

NARRATIVE

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On September 5, 2021, R1 began hospice services. On September 8, 2021, R1 passed away. R1’s responsible party had paid the facility $7,000 for care of R1 for the month of September 2021. On September 9, 2021, R1’s responsible party removed R1’s belongings from the facility. At this time, R1’s responsible party inquired about receiving a refund. Staff at the facility told the responsible party that the Licensee would need to be contacted regarding any refunds.

Interviews and review of facility records revealed that the facility has a policy of not providing refunds to any residents that receive hospice or palliative care services. Facility records reviewed revealed that there is an admission agreement addendum that states “In the event that a resident is admitted to palliative care or hospice, the basic monthly fee and admission deposit, if any is non- refundable. This is due to extra expenses of PPE and extra expenses of such care”. Facility records reviewed indicate that R1’s responsible party had signed an addendum stating the former. Interviews with the licensee revealed that although there is a no refund policy addendum as part of the admissions agreement, she uses her discretion as to when this policy is implemented and will work with families if they have an issue with the policy.

The Department notified the Licensee of the complaint on September 21, 2021. On September 24, 2021, R1’s responsible party was provided a refund of more than $4,000. Interviews with staff and outside sources corroborate that a refund was given. The refund of the balance of rent paid in September 2021 was provided to R1’s responsible party within required 15 days of R1’s belongings being removed from the facility.

(CONTINUED ON LIC 9099-C, 2 of 3)

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina Ryan	TELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20210913142247

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: LILAC CHATEAU 1	FACILITY NUMBER: 374603155
	VISIT DATE: 11/15/2021

NARRATIVE

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During the course of the Department’s investigation, records revealed that there were at least two additional former residents’ responsible parties that did not receive a refund for the balance of rent after the residents passed when the residents were receiving hospice services. Interviews with these former residents’ responsible parties revealed that they did not realize that they could potentially have a refund, so they never inquired. Resident 2 (R2) was admitted into the facility on October 29, 2015. R2 began hospice services on August 16, 2021 and passed away on September 3, 2021. R2 had prepaid the facility approximately $ 5,000 for the month of September 2021 prior to them passing. R2’s responsible party removed R2’s belongings from the facility approximately a week after R2’s death.

Unlike R1, R2 and/or their responsible party had not signed the addendum to the admission agreement. Resident 3 (R3) was admitted to the facility on October 17, 2016. R3 began hospice services on May 27, 2021 and passed away on June 6, 2021. R3 has a signed addendum to the admission agreement in their file that stated they would not receive a refund. R3’s responsible party stated that R3’s belongings were removed from the facility within a few days of their passing. R3’s responsible party had prepaid the facility approximately $ 5,000 for care of R3 in June 2021. A review of the addendum revealed the Department had not approved the change to the Admission Agreement and it was determined to not meet the Health and Safety Code.

Based on interviews, and reviewed records, a preponderance of evidence exists to substantiate the allegation. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly created with the licensee. An exit interview was completed with the licensee, to whom a copy of this report, LIC 811 (Confidential Names List) and the Licensee/Appeal Rights (LIC9058 01/16) were provided via e-mail.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina Ryan	TELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 08-AS-20210913142247

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: LILAC CHATEAU 1	FACILITY NUMBER: 374603155
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/09/2021 Section Cited HSC 1569.652(c)	1 2 3 4 5 6 7	1569.652 (c) Termination of admission agreement upon death of resident; removal of resident’s property, refund of fees paid; notice of contract termination and refunds. A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual,...or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed. This requirement was not met by;	1 2 3 4 5 6 7	Licensee will refund the balance of rent due to R2 and R3'S estate or responsible party. Licensee will refund the amount due on or before December 6, 2021. Licensee will provide documentation to LPA of payment on or before December 6, 2021.
	8 9 10 11 12 13 14	Based on interviews and records review, the licensee did not refund any fees paid in advance covering the time after the resident’s personal property had been removed from the facility for 2 of 6 persons in care, which posed a potential Personal Rights risk to persons in care.	8 9 10 11 12 13 14	Licensee will remove unlawful addendum to the admission agreement, will notify all current residents of unlawful addendum, and provide updated admission agreement to LPA on or before December 20, 2021
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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 Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina Ryan	TELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021

LIC9099 (FAS) - (06/04)

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