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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405800923
Report Date: 12/17/2024
Date Signed: 12/17/2024 11:20:28 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/10/2024 and conducted by Evaluator Melisa Rankin
COMPLAINT CONTROL NUMBER: 29-AS-20241210132533
FACILITY NAME:SOUTHBAY MAXI CAREFACILITY NUMBER:
405800923
ADMINISTRATOR:LITA C. LAZOFACILITY TYPE:
740
ADDRESS:1410 13TH STREETTELEPHONE:
(805) 528-1725
CITY:LOS OSOSSTATE: CAZIP CODE:
93402
CAPACITY:6CENSUS: 4DATE:
12/17/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Lita LazoTIME COMPLETED:
11:20 AM
ALLEGATION(S):
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Licensee did not provide a refund to resident's responsible person
INVESTIGATION FINDINGS:
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On 12/17/24 at 9:45 am, Licensing Program Analyst (LPA) Rankin conducted an unannounced complaint visit to the facility above to review allegations of complaint. LPA met with Administrator Lita Lazo and explained the purpose of the visit.

On the allegations: Licensee did not provide a refund to resident's responsible person

It was alleged by the reporting party that the licensee failed to refund the pro-rated amount of the monthly payment after the passing of Resident #1 (R1). Investigation consists of facility admission agreement with resident, interview with administrator and responsible person. LPA learned that R1 moved in in June of 2021 and passed away on 05/08/24. Interviews revealed that resident’s belongings were removed the same day on 05/08/24 by responsible party and 2 witnesses.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
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 29-AS-20241210132533
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SOUTHBAY MAXI CARE
FACILITY NUMBER: 405800923
VISIT DATE: 12/17/2024
NARRATIVE
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Continued from 9099

Resident’s admission agreement states that “refund is based on the number of unused days. Refund to be issued within ten (10) days from the last day of either stay or when all belongings are removed from the facility.” Resident #’1’s rent for the month of May 2024 was paid in full at the beginning of month. Refund was requested however administrator/licensee failed to issue refund.

Per Admission agreement and Health and Safety Code 1569.652 (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 or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed.”

Facility administrator failed to refund the pro-rated amount of the monthly rent, 05/08/24 to 05/31/24, to R1's responsible party within the required time frame required by California State law.

Therefore, the allegation " Licensee did not provide a refund to resident's responsible person " is deemed substantiated.

Exit interview conducted, citations, copy of report and appeal rights issued.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20241210132533
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SOUTHBAY MAXI CARE
FACILITY NUMBER: 405800923
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/31/2024
Section Cited
HSC
1569.652(c)
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1569.652 Termination of admission agreement upon death of resident...(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...within 15 days after the personal property is removed.
This requirement is not met as evidenced by:
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Administrator will ensure a refund is sent to R1’s family by 12/31/24 and send evidence of the payment via email to LPA.
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Based on interviews and records review, the licensee did not comply with the section cited above. Licensee failed to provide R1’s Representative with a refund within 15 days after R1 passed away and personal belongings removed, which posed a potential health, safety, or personal rights 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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3