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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701008
Report Date: 02/25/2022
Date Signed: 02/25/2022 03:48:39 PM



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
02/02/2022 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20220202144224
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: 9DATE:
02/25/2022
UNANNOUNCEDTIME BEGAN:
12:54 PM
MET WITH:Nataley MartinezTIME COMPLETED:
01:50 PM
ALLEGATION(S):
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Facility failed to issue a refund
INVESTIGATION FINDINGS:
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On 2-25-22 at 12:54pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the complaint allegation noted above. LPA met with Nataley Martinez and explained the purpose of the visit. During this investigation LPA reviewed admission agreement for resident1 (R1), proof of payment for residency of R1, refund check issued to R1's responsible person and post marked date of envelope for refund check issued to R1's responsible person. LPA also interviewed licensee and R1's responsible person. Based on interview and record review, R1 passed away on 2-1-22 and all personal belongings were removed on 2-4-22. Based on interviews and record reviews it is determined that R1's responsible person was to receive a refund of money owed for a previous residency by 2-19-22. On 2-25-22, based on interview and record review, R1's responsible person received refund check post dated for 3-1-22 with a post marked date on the accompanyinig envelope of 2-23-22. Based on interview and record review the preponderance of evidence standard is met. Therefore, this allegation is SUBSTANTIATED. An exit interview was held with Nataley Martinez and a copy of this report was given to Nataley. Appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022
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 2
Control Number 27-AS-20220202144224
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: 02/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2022
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 will read regulation 1569.652 and send a signed letter of understanding to LPA by POC due date.

Licensee will provide payment due to R1's responsible party to arrive by 2-28-22. Licensee to provide proof of payment made to LPA by POC due date.
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This requirement is not met as evidenced by: Based on interview and record review, R1's responsible party received a post-dated refund check dated 3-1-22 on 2-25-22 which was due to R1's responsible party on 2-19-22. accompanied post marked envolope was dated 2-25-22. 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: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2