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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604490
Report Date: 02/16/2023
Date Signed: 02/17/2023 10:38:41 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
01/18/2023 and conducted by Evaluator Debbie Correia
COMPLAINT CONTROL NUMBER: 08-AS-20230118101754
FACILITY NAME:COLLEGE TOWN SENIOR RETIREMENT VILLA INCFACILITY NUMBER:
374604490
ADMINISTRATOR:PETROSYAN, ANNAFACILITY TYPE:
740
ADDRESS:5252 STONE CTTELEPHONE:
(619) 432-1236
CITY:SAN DIEGOSTATE: CAZIP CODE:
92115
CAPACITY:6CENSUS: 6DATE:
02/16/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Caregiver Nvard BedekyanTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Staff did not issue authorized representative a 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. LPA identified herself to Caregiver Nvard Bedekyan to whom was explained the purpose of the visit.

The department’s investigation consisted of staff and outside source interviews. The investigation also included a facility and outside source records review.

It was alleged facility staff did not issue reimbursement upon Resident1’s (R1) death. An outside source interview revealed R1 moved into the facility on August 4, 2022, and passed away on August 6, 2022. Interviews with outside sources revealed R1’s belongings were removed from the facility on August 8, 2022. A resident records review corroborated the duration R1 was at the facility. Outside source interviews and records review also revealed a monthly payment of $6,700 was issued to the facility on August 3, 2022, which included a $500 pre-admission fee.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
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-20230118101754
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: COLLEGE TOWN SENIOR RETIREMENT VILLA INC
FACILITY NUMBER: 374604490
VISIT DATE: 02/16/2023
NARRATIVE
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A facility records review corroborated the amount paid for R1’s admission and monthly rate. Interviews with facility staff and outside sources confirmed a refund for the days included in the monthly rate, following the day of R1’s passing and removal of belongings from the facility, had not been issued at the time the Department received the complaint filed on January 18, 2023.

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. LPA Correia conducted an exit interview with Caregiver Nvard Bedekyan .

At the time of the exit interview Caregiver Nvard Bedekyan was given a copy of the Complaint Investigation Report (LIC9099), and Licensee Rights (LIC9058 01-2016), and signature on this report acknowledges receipt of the rights.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20230118101754
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: COLLEGE TOWN SENIOR RETIREMENT VILLA INC
FACILITY NUMBER: 374604490
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/10/2023
Section Cited
CCR
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...

This requirement was not met as evidenced by:
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Licensee Petrosyan provided a $4800 refund to R1's Responsible Party (RP) dated 1/20/2023. Licensee agrees to refund the balance of $350 by POC Date. Facility staff will also attend an on-line CDSS certified course on Title 22 refund regulations.
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Based on interviews and records reviews 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.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3