374603913-1-20-2023-08-AS-SJAB-CNLNUN-20230131094634

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603913
Report Date: 01/20/2023
Date Signed: 01/20/2023 01:53:15 PM

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
12/27/2022 and conducted by Evaluator Esther Miller

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20221227133158

FACILITY NAME:	NOBLE LIVING II LLC		FACILITY NUMBER:	374603913
ADMINISTRATOR:	BUNNELL, DEBRA		FACILITY TYPE:	740
ADDRESS:	505 HILLS LANE DR		TELEPHONE:	(619) 938-4984
CITY:	EL CAJON	STATE: CA	ZIP CODE:	92020
CAPACITY:	6	CENSUS: 4	DATE:	01/20/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Nora Garcia, Administrator		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Facility did not refund money owed after resident's death.
Licensee did not provide a signed copy of the Admissions Agreement to authorized representative.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Esther Miller conducted an unannounced complaint investigation visit to deliver findings on the above allegations. LPA was granted entry by Victoria Bozzo, caregiver, after identifying herself. LPA discussed the purpose of the visit and the basic elements of the allegations mentioned above with Nora Garcia, Administrator. Licensee Debra Bunnell arrived during the visit.

On December 27, 2022, it was alleged that the facility did not refund money owed after resident’s death, specifically that resident did not get a full refund. It was also alleged that the Licensee did not provide a signed copy of the Admissions Agreement to a resident’s authorized representative. The Department’s investigation consisted of review of facility records, and interviews with facility staff, residents, and outside sources.

[Continued on LIC9099-C, Page 1 of 2]

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther Miller	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

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-20221227133158

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: NOBLE LIVING II LLC	FACILITY NUMBER: 374603913
	VISIT DATE: 01/20/2023

NARRATIVE

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[Continued from LIC9099, Page 2 of 2]

On December 2, 2022, Administrator stated that two blank copies of the Admissions Agreement were given to Resident 1’s (R1 - See LIC811 Confidential Names List) Power of Attorney (POA) for POA to review the agreement at home. The next day, POA returned a signed copy of the Admissions Agreement to the facility. Administrator admitted she did not provide a signed copy because she had given a blank copy to POA previously. In the Admissions Agreement was an addendum signed by POA and Administrator stating that a refund would not be due if a resident on hospice died within the first thirty (30) days of moving into the facility. Facility records showed R1’s care for December 2022 was paid for on December 2, 2022. The signed Admissions Agreement stated that an preadmission fee was not being charged.

On December 6, 2022, R1 passed away while on hospice. Outside sources, Licensee, and Administrator confirmed R1’s personal belongings were taken out of R1’s room on the same day, December 6, 2022, leaving only a medical bed and oxygen machine in the room. Outside sources indicated the bed and oxygen machine were considered durable medical equipment (DME) and belonged to an agency contracted by R1’s hospice agency. Outside sources confirmed that the DME was rented to hospice and not the resident. Outside source, Licensee, and Administrator confirmed the bed and oxygen machine were taken out on December 12, 2022. Licensee maintained the DME was considered personal belongings.

Licensee chose to refund POA after resident’s death, despite the addendum signed by POA. The date the DME was removed from the facility factored into the refund amount and the date refund was issued. Facility’s refund invoice showed that an admissions fee and a rush fee were charged. Licensee maintained that the fees were verbally agreed to by POA and no written documentation of the fees were created. Outside source records revealed a refund check was issued to R1’s authorized representative on December 21, 2022.

Based on the evidence obtained during the complaint investigation, the allegations that the facility did not refund money owed after resident's death and that the Licensee did not provide a signed copy of the Admissions Agreement to authorized representative is found to be SUBSTANTIATED, as there is a preponderance of evidence to show the violation occurred. Pursuant to the California Code of Regulations, Title 22, Division 6, deficiency is being cited on the attached LIC9099D and a plan of correction was jointly developed with Administrator. An exit interview was conducted; a copy of this report and Licensee's Rights (LIC9058) were provided.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther Miller	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20221227133158

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: NOBLE LIVING II LLC	FACILITY NUMBER: 374603913
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/20/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/27/2023 Section Cited CCR 87507(h)(4)	1 2 3 4 5 6 7	Admission Agreements: (h)The admission agreement shall not contain...: (4) Any provision that violates the rights of any residents...specified...in Health and Safety Code section 1569 et seq. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to not include hospice addendum in future Admissions Agreements. Licensee will provide proof in-service training on section 87507. Refund of $2866.67 will be issued to R1's POA; certfied mail receipt and copy of cashier's check will be sent to LPA as proof.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee included unlawful provisions in the Admissions Agreement which posed a personal rights risk to persons in care.	8 9 10 11 12 13 14
Type B 01/27/2023 Section Cited CCR 87507(e)	1 2 3 4 5 6 7	Admission Agreements: (e) The licensee shall provide a copy of the signed and dated current admission agreement…to...the resident's representative…immediately upon signing the admission agreement… This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will send a signed copy of the Admissions Agreement to R1 and send LPA certified mail receipt. Licensee will include Receipt of Admissions Agreement to future Admissions Agreement.
	8 9 10 11 12 13 14	Based on interviews and record reviews, the licensee did not provide a signed Admissions Agreement which posed a personal rights risk to residents in care.	8 9 10 11 12 13 14

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: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther Miller	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC9099 (FAS) - (06/04)

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