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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701008
Report Date: 03/18/2022
Date Signed: 03/18/2022 11:44:31 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, 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
03/17/2022 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20220317164418
FACILITY NAME:PLACE CALLED HOMEFACILITY NUMBER:
392701008
ADMINISTRATOR:VARGAS, BRANDIFACILITY TYPE:
740
ADDRESS:25820 MAGNOLIA AVETELEPHONE:
(714) 948-0381
CITY:ESCALONSTATE: CAZIP CODE:
95320
CAPACITY:11CENSUS: 0DATE:
03/18/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Nataley MartinezTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility failed to issue a refund
INVESTIGATION FINDINGS:
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On 3-18-22 at 10:00 am, Licensing Program Analysts (LPAs) Michael Bilger and Maja Jensen arrived unannounced to open a complaint regarding the allegation noted above. LPAs met with Licensee Nataley Martinez and explained the purpose of the visit.

During the course of this investigation, LPAs interviewed Licensee Nataley Martinez, the responsible party for resident 1 (R1) and the Administrator (on 3/17/22). LPAs confirmed with Licensee Nataley Martinez that a refund had not been issued to R1s responsible party to date. In addition, LPAs reviewed the file for R1 including the admission agreement.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
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 27-AS-20220317164418
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: PLACE CALLED HOME
FACILITY NUMBER: 392701008
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/18/2022
Section Cited
HSC
1569.652(c)
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1569.652(c)...Refund of fees paid: (c)A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees...within 15 days after the personal property is removed.
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Licensee to complete electronic transfer of funds to responsible party during course of visit. Recept of electronic transfer of funds confirmed by LPAs over telephone call with responsible party during course of visit. Responsible party also confirmed the amount received was correct.
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This requirement is not met as evidenced by: Based on interview and record review, R1's responsible party did not receive a refund on or before the due date of 1/23/22. This poses a potential resident rights risk to 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.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20220317164418
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: PLACE CALLED HOME
FACILITY NUMBER: 392701008
VISIT DATE: 03/18/2022
NARRATIVE
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A record review was conducted. The admission agreement indicates that a refund will be issued within 15 days after property is removed from the facility. Based on interviews and record review R1 passed away on 12/31/21. The responsible party for R1 collected R1's belongings owhich 15 days after R1's personal belongings were collected, therefore, this allegation is SUBSTANTIATED.

An exit interview was held with Nataley Martinez and a copy of this report was given to Nataley Martinez. Appeal rights provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3