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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 410508376
Report Date: 12/14/2022
Date Signed: 12/14/2022 10:30:46 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/18/2022 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20221118132153
FACILITY NAME:DOLPHIN PARK REST HOME #3FACILITY NUMBER:
410508376
ADMINISTRATOR:CONANAN, EVELYNFACILITY TYPE:
740
ADDRESS:380 GUNTER LANETELEPHONE:
(650) 593-4965
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94065
CAPACITY:6CENSUS: 4DATE:
12/14/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Evelyn ConanTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Facility staff refused to issue refund to resident's authorized representative
INVESTIGATION FINDINGS:
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On December 14, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Administrator, Evelyn Conan and explained the purpose of the visit.

Regarding the allegation that facility staff refused to issue refund to resident’s authorized representative, according to the reporting party, the Administrator was not going to issue a refund upon a resident’s death. During the investigation, LPA reviewed resident files and observed the facility admissions agreement. According to the Administrator, there is a no refund policy based on the facility’s admission agreement. Based on the admission agreement reviewed, it states, “In the event of a death, no refund shall be given based on daily rate.”

Although the admission agreement indicates that there is no refund issued upon resident’s death and the authorized representative signed the admission agreement, the facility’s admission agreement does not meet Title 22, Div. 6, Chapt. 8, Article 9, Sec. 87507 Admission Agreements. Nevertheless, the facility administrator failed to ensure that the facility’s admission agreement met CCR 87507 as the refund conditions as required was not included in the facility's admission agreement.

Based on the information collected and interviews conducted, it was determined that facility accepted resident with a 3 pressure injury without an exception. The preponderance of evidence standard has been met; therefore, the above allegation is determined to be Substantiated.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with Administrator, Evelyn Conan and a copy is provided with appeals rights.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
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 14-AS-20221118132153
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: DOLPHIN PARK REST HOME #3
FACILITY NUMBER: 410508376
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/21/2022
Section Cited
CCR
87507(g)(5)(A)(1)
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87507 Admission Agreements: (g) Admission agreements shall specify the following... (5) Refund conditions...(A) Facility policy concerning refunds...a refund for advanced monthly fees will be returned in the event of a resident’s death, pursuant to Health and Safety Code section 1569.652..1. Written notice...must be made to the individual... responsible for the payment of the resident’s fees...
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Facility administrator to submit a plan of action to licensing by 12/21/22 to describe how facility plans to provide the refund per regulations or as required to family member and refund policy moving forward. In additional facility to submit a revised admission agreement to meet CCR 87507(g)(5)(A) by 12/21/22.
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Violation of this regulation is evidenced by: Based on the facility's admission agreement reviewed, there is no refund issued to resident's responsible party in the event of a resident's death. In addition, the facility's admission agreement does not meet CCR 87507 regarding refund policy.
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Administrator to reach out to family member by 12/21/22 indicating the amount of refund to be issued. Administrator to provide LPA with a copy of the check as proof by 12/30/22.
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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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2