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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604326
Report Date: 11/29/2022
Date Signed: 11/29/2022 08:44:13 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
03/19/2021 and conducted by Evaluator Debbie Correia
COMPLAINT CONTROL NUMBER: 08-AS-20210319105322
FACILITY NAME:OASIS VILLAGE CAREFACILITY NUMBER:
374604326
ADMINISTRATOR:SAHID, RAMLAFACILITY TYPE:
740
ADDRESS:3865 SHIRLENE PLTELEPHONE:
(619) 727-7335
CITY:LA MESASTATE: CAZIP CODE:
91941
CAPACITY:6CENSUS: 6DATE:
11/29/2022
UNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:House Manager (HM), Abdi Aziz HusseinTIME COMPLETED:
03:19 PM
ALLEGATION(S):
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Facility failed to provide a refund upon resident’s death.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to deliver investigative findings on the above listed complaint allegation, LPA was met and granted entry into the facility by House Manager (HM) Hussein to whom was explained the purposes for the visit.

The Department’s investigation consisted of staff and outside source interviews . The investigation also included a facility and residents record review.

It was alleged facility staff did not issue a refund after the death of Resident1 (R1). An outside source interview (OS1) revealed R1 was admitted to the facility on January 23, 2021 with a payment of a full 30 days of rent. At the time of admission R1 was on hospice with a diagnosis of Alzheimer’s and several other secondary heath conditions. The interview with OS1 and a resident records review revealed R1 declined quickly and passed away on January 28, 2021.
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: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
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-20210319105322
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: OASIS VILLAGE CARE
FACILITY NUMBER: 374604326
VISIT DATE: 11/29/2022
NARRATIVE
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Additional outside source interviews revealed all hospice supplies were picked up on the same day of R1’s passing however some of R1’s personal belongings were left at the facility for an additional 15 days. Interviews with both the Licensee and OS1 corroborated R1’s personal belongings remained at the facility for approximately 15 days after R1’s passing, leaving a total of 10 days of pre-paid care. Per Title 22 code of regulations and Health and Safety code all fees paid for after the death of a resident and removal of personal belongings shall be refunded.

Based on interviews and records reviews conducted the above allegation is determined to be substantiated. A substantiated finding means the allegations are valid because the preponderance of evidence standard has been met. Deficiency is cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on the LIC 9099-D.

An exit interview was conducted with HM Hussein and a copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) was provided to Signature on this form confirms receipt of the documents.


SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20210319105322
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: OASIS VILLAGE CARE
FACILITY NUMBER: 374604326
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2022
Section Cited
HSC
1569.652(A)
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Termination of admission agreement upon death...removal of resident’s property; refund of fees paid; notice of contract termination and refund. A residential..shall not require...notice for terminating an admission agreement upon...death...No fees shall accrue once all personal property...is removed. This requirement was not met as evidenced by:
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House Manager Hussein and Licensee Sahidin agreed to issue the refund for ten days of paid for care to R1's Responsible Party by the POC due date.
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Based on interviews and record reviews, the Licensee did not ensure a refund of pre-paid fees after the death of R1. This poses a potential personal rights risk to 1 out of 5 clients 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: 11/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3