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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700332
Report Date: 11/06/2020
Date Signed: 11/11/2020 08:36:42 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/03/2019 and conducted by Evaluator Albert Johnson
COMPLAINT CONTROL NUMBER: 27-AS-20191203152203
FACILITY NAME:A PLACE CALLED HOME IIFACILITY NUMBER:
392700332
ADMINISTRATOR:MARTINEZ, RYTAFACILITY TYPE:
740
ADDRESS:25820 MAGNOLIA AVETELEPHONE:
(209) 986-3949
CITY:ESCALONSTATE: CAZIP CODE:
95320
CAPACITY:11CENSUS: 10DATE:
11/06/2020
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Lesley PinolaTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Financial Abuse
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Albert Johnson, Licensing Program Manager (LPM) Liza King, Auditor Diana Chapman and Regional Manager (RM) Krystall Moore met with Licensee Lesley Pinola via Web X to deliver findings for the complaint investigation due to COVID-19 and pre-cautionary measures. The Department reviewed facility, resident, and staff files, conducted relevant party interviews, obtained relevant documentation and evidence

Based on records reviewed by the Department, the licensee mishandled R1's funds and used undue influence to charge R1 for advance payment for life care. The facility is not licensed as a Continuing Care Facility. R1 was on hospice and had limited life expectancy based on the hospice report dated 8/23/2019 and 9/23/2019.

Further investigation determined that the facility did not have records to identify personal property for R1 and did not have an admissions agreement, However, the Department subpoenaed records from the bank account of R1 and from the bank records,

Continued on 9099C attached
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2020
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 27-AS-20191203152203
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: A PLACE CALLED HOME II
FACILITY NUMBER: 392700332
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
HSC
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Removed
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Type B
11/16/2020
Section Cited
CCR
87218(a)(1)(2)
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Theft and Loss(a) The licensee shall ensure an adequate theft and loss program as specified in (a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153.
(1) The initial personal property inventory shall be completed by the licensee, and the resident, or the resident’s representative.

(2) A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse a resident for or replace stolen or lost resident property at its current value. The licensee shall be presumed to have made reasonable efforts to safeguard resident property if there is clear and convincing evidence of efforts to meet each requirement specified in Section 1569.153.
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Licensee will update and submit, for CCL review and approval, facility's plan of operation to include detailed theft/loss prevention program. Furthermore the
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This requirement was not met as evidenced by interviews and review of facility records. The facility was unable to produce records for review which contributed to the failure to protect R1's personal property upon R1's death.
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Licensee will reimburse R1's estate for lost resident property identified in this report at its current value. by POC date 11/16/2020
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: Liza KingTELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20191203152203
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: A PLACE CALLED HOME II
FACILITY NUMBER: 392700332
VISIT DATE: 11/06/2020
NARRATIVE
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the department confirmed that R1 was paying $8,900.00 dollars for August and September of 2019 with extra care cost in September at $1,000.00 and rent for October 2019 was $10.500.00 with two additional checks, these checks were confirmed for rent by the identified memo area of the checks in the amounts of $1,500 and $29,000.00 which were also deposited. Another check in October 2019 in the amount of $6,000.00 was identified in the memo area as "extra care Aug-Nov". Two checks in November 2019 in the amounts of $1,000.00 and $5,500.00 were identified as care and rent care. The final check in November 2019 in the amount of $240,000.00 for "Care for Life". This was identified as questionable by R1's bank. When the Licensee/ Administrator was asked about the funds, she stated that "R1 was a family friend and now is in their care and the money was a loan and advance payment for two years of care." R1 passed away on 12/2/2019.

Based on limited records for R1, the Department was able to establish that R1 was on hospice, but was unable to determine when hospice was initiated. The agencies documents had different dates 8/23/2019 and 9/23/2019 and a change to a different providers on 10/7/2019.

As a result of this investigation, the Department finds the allegations to be Substantiated. A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies are cited on 9099-D, per Title 22 Regulations, Division 6.

Licensees was informed that the Department will be referring A Place Called Home II, A Place Called Home's license and Administrator's certificates to the Department's Legal Division for Administrative Action.

Exit interview was conducted with Licensee where LPA reviewed report. An electronic copy of the report was emailed to the facility to obtain a signature from the Licensee and emailed back to LPA to be filed.



SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3