374604267-10-2-2024-08-AS-LTEZ-DAHPVM-20241029113918

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604267
Report Date: 10/02/2024
Date Signed: 10/02/2024 04:12:52 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
09/26/2024 and conducted by Evaluator Iby Strong

COMPLAINT CONTROL NUMBER: 08-AS-20240926070542

FACILITY NAME:	CLOISTERS OF THE VALLEY, LLC		FACILITY NUMBER:	374604267
ADMINISTRATOR:	DISHA FRANCES-HALL		FACILITY TYPE:	740
ADDRESS:	4171 CAMINO DEL RIO SOUTH		TELEPHONE:	(619) 283-2226
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92108
CAPACITY:	70	CENSUS: 60	DATE:	10/02/2024
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Business Director Suzie Dizon		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Licensee financially abused resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to initiate a complaint investigation on the above-mentioned allegation. LPA identified herself and discussed the purpose of the visit with Business Director Suzie Dizon.

On September 26, 2024, Community Care Licensing (CCL) received a complaint alleging licensee financially abused Resident 1 (R1).

During the investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. According to the allegation, R1 is expected to pay roughly $1398 per month out of pocket but is only receiving $1261 monthly from Social Security Income and the remaining balance of $137 per month is accumulating an ongoing balance for R1. Admissions Agreement reviewed revealed that R1 and responsible party agreed to a total monthly expense of $5,450 per month on October 24, 2023.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

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 08-AS-20240926070542

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CLOISTERS OF THE VALLEY, LLC	FACILITY NUMBER: 374604267
	VISIT DATE: 10/02/2024

NARRATIVE

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Agreement also revealed that R1 is actively receiving the Assisted Living Waiver (ALW) reducing the required monthly room and board fee to $1324. Records also revealed that the ALW room and board fee increased in January 2024 to $1398 per month. ALW Addendum to Residency Agreement reviewed states the following “If the resident’s total income is less than the required amount of $1324 Resident/Power of Attorney or Responsible Party will need to work with the CCA assigned case manager to increase the income to meet the minimum amount set”. Interview with Business Director corroborated that residents are responsible for paying the full room and board portion directly to the facility. Interview with outside source revealed that this discrepancy may be cleared up by contacting Social Security.

Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Business Director Suzie Dizon, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

LIC9099 (FAS) - (06/04)

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