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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600616
Report Date: 05/20/2021
Date Signed: 05/21/2021 10:43:12 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/17/2021 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20210517085607
FACILITY NAME:NEW CEDAR LANE CARE HOME, INC.FACILITY NUMBER:
415600616
ADMINISTRATOR:DIAZ, YOLANDAFACILITY TYPE:
740
ADDRESS:924 CEDAR STREETTELEPHONE:
(650) 728-3132
CITY:MONTARASTATE: CAZIP CODE:
94037
CAPACITY:17CENSUS: 11DATE:
05/20/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Yolanda DiazTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Facility illegaly evicted resident
Facility did not refund preadmission fee
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Murial Han and Licensing Program Analyst (LPA) Audrey Jeung met with Ms. Diaz to discuss the allegations and reviewed file for former resident (R1).
On 3/20/21, (R1) became highly agitated and physically assaulted former assistant administrator. After this incident, the facility staff called R1's responsible party to request that resident be picked up and removed from facility; resident was picked up by responsible party and has not returned. Prior to this incident, resident had occasional outbursts and episodes of agitation. Facility failed to issue notices of 30-day eviction nor 3-day eviction.

Admission agreement for R1 does not include pre-admission fee/community/administrative fee. Responsible party paid $2000 and has not received any refund of this fee.

Based on this information, the preponderance of evidence standard has been met. Therefore, these allegations are determined to be substantiated.
Deficiencies of the CA Code of Regulations, Title 22 are cited on a following page.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021
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-20210517085607
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: NEW CEDAR LANE CARE HOME, INC.
FACILITY NUMBER: 415600616
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/03/2021
Section Cited
CCR
87224(b)
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EVICTION PROCEDURES
The licensee may, upon obtaining prior written approval from CCLD, evict the resident upon 3 days written notice. CCLD may grant approval for the eviction upon a finding of good cause, which exists if the resident is engaging in behavior
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Plan of correction to be submitted to CCLD BY DUE DATE
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which is a threat to the mental and/or physical health or safety of himself or others in the facility. This requirement was not met, as licensee failed to provide written notice to R1 when he was asked to leave the facility. This posed a potential health, safety or personal rights risk to client.
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Type B
06/03/2021
Section Cited
CCR
87507(g)(3)(C)(1)
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ADMISSION AGREEMENTS
Any fee that is charged prior to or after admission, shall be clearly specified. Licensee must provide the applicant or representative with a written general statement describing all costs associated with the preadmission fee charges and
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Plan of correction to be submited to CCLD BY DUE DATE, which shall include full refund of community/admin fee and elimination of this fee or inclusion of this refundable fee in revised admission agreement
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stating that the preadmission fee is refundable, and describing conditions for the refund. This requirement was not met, as pre-admission fee was not included in AA for R1 when signed by authorized representative. This posed a potential personal rights risk to client.
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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: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2