405801845-3-14-2023-29-AS-KBUY-CQDNYE-20230329105237

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405801845
Report Date: 03/14/2023
Date Signed: 03/14/2023 04:44:10 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/08/2023 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20230308113048

FACILITY NAME:	GRACEFUL LIVING 2		FACILITY NUMBER:	405801845
ADMINISTRATOR:	JEFFIFER LAWRENCE		FACILITY TYPE:	740
ADDRESS:	389 SPANISH MOSS LANE		TELEPHONE:	(805) 489-3286
CITY:	ARROYO GRANDE	STATE: CA	ZIP CODE:	93420
CAPACITY:	6	CENSUS: 6	DATE:	03/14/2023
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Jennifer Lawrence, Administrator/Licensee		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Facility did not provide a deceased resident records to resident's authorized representative.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) De Leon conducted a 10 day complaint visit to the facility above. LPA met with Administrator/Licensee Jennifer Lawrence and explained the purpose of the visit.

LPA requested Resident 1's (R1) records for review.

On the allegation: Facility did not provide a deceased resident records to resident's authorized representative. Administrator/Licensee explained that due to the rain storms in December of 2022 all the facilities inactive files stored in shed were destroyed by flooding. Continued 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230308113048

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GRACEFUL LIVING 2	FACILITY NUMBER: 405801845
	VISIT DATE: 03/14/2023

NARRATIVE

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Administrator stated the facility had a total loss of 31 inactive residents records destroyed. Administrator sent LPA photographs of the flooding to the property and insurance claim submitted for the flooding to the property. Administrator was not able to produce the records requested to the authorized representative (AR) and explained it was due to the flooding that occurred at the off site storage. Administrator sent an email to the AR stating AR could get some of the records requested through the residents PCP doctor and the Hospice Agency that provided hospices services to R1. Administrator confirmed with R1's doctor and hospice agency that these records were provided to the AR. Administrator stated the facility does not destroy any records until after the 3 years that regulation allows and would produce the records if able. Administrator mailed a copy of the all the blank admissions forms/paperwork to the AR. Based on the evidence the administrator could not produce the records due to unforeseen circumstances of the flooding in a natural disaster this allegation is deemed Unsubstantiated at this time.

LPA issued a Technical Advisory for best practices to avoid this from reoccurrence in the future.

Exit interview conducted, Technical Advisory issued, copy of report printed for Administrator/Licensee.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

LIC9099 (FAS) - (06/04)

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