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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 08:37:44 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
12/09/2019 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20191209161007
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
ANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Lesley PinolaTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility is unable to account for residents personal belongings:
including: Van, IPAD, $5000 TV
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 facility did not properly safeguard the belonging of R1 upon R1's death. Further investigation determined that the facility did not have records to identify personal property for R1 and did not have an admissions agreement for review by the Department.

The Department confirmed that the van of R1 was given to R1's cousin (C1), however, the Department was unable to locate the $5,000 dollar TV, IPAD and other recently purchased personal items. Continued on 9099C
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: 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
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 4
Control Number 27-AS-20191209161007
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 A
11/09/2020
Section Cited
CCR
87405(d)(1-7)
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87405(d) Administrator - Qualifications and Duties: (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
This requirement was not met by:
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The Licensee will receive outside training from a CDSS vendored agency to address Ethic, personal rights and personal conduct. By POC due date
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Based on interviews, records, observation, the Administrator demonstrated lack of knowledge of and ability to conform to the applicable laws, rules and regulations and/or have good character and a continuing reputation of personal integrity. This poses an immediate health and safety risk.
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CCR
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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: 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 4
Control Number 27-AS-20191209161007
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
11/16/2020
Section Cited
HSC
1569.652
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§1569.652 Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds. This requirement was not met as evidenced by: The
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Licensee is to refund the amount of ($276,000.00 dollars) to the responsible party, fiduciary, trustee or to the Estate of R1 and proof submitted to Licensing by POC due date 11/16/2020. The check should be made out to "Frances Bascom Trust."
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lack of an admissions agreement for R1, missing documents to support extra care and information regarding life expectancy of six month or less. This poses a potential health and safety risk.
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The Licensee will provide the department with a receipt for the purchase of the television and the i pad that was purchased at Costco by the POC date 11/16/2020.
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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: 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: 3 of 4
Control Number 27-AS-20191209161007
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 facility had no record of R1's personal items. The Administrator/ Licensee did not maintain records/document that are required to be in the resident's file at all times and the facility did not properly safeguard R1's personal belongings upon her death.

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, and 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: 4 of 4