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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600750
Report Date: 12/07/2020
Date Signed: 12/07/2020 02:51:05 PM



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
11/25/2020 and conducted by Evaluator Christopher Hopkins-Clarke
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20201125154138
FACILITY NAME:JUDY'S HOMES FOR THE ELDERLY, INC.FACILITY NUMBER:
415600750
ADMINISTRATOR:ROIAS, JUDYFACILITY TYPE:
740
ADDRESS:3415 PACIFIC BLVD.TELEPHONE:
(650) 458-3262
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:6CENSUS: 4DATE:
12/07/2020
UNANNOUNCEDTIME BEGAN:
11:23 AM
MET WITH:Mercy MoreiraTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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-Facility failed to issue a refund
INVESTIGATION FINDINGS:
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On 12/7/20 Licensing Program Analyst (LPA) Chris Hopkins conducted an unannounced complaint investigation regarding the above allegation. LPA met with Administrator Mercy Moreira via tele-visit due to Covid-19 procedures and explained the purpose of the tele-visit.

Regarding the allegation that facility failed to issue a refund, the Department investigation found the following: The complainant said that around 11/12/20, a potential resident, or his/her representatives, discussed admission to this facility. The licensee or representative indicated that prior to client's admission, he/she was required to pay a deposit of $3500 to hold a room, which the potential resident paid. Although no admission was signed, the check issued to the licensee stated that the money was a deposit. The client did not move in, and did not sign an admission agreement, but asked for the refund of the “deposit”. The licensee, or facility representative, responded with a note stating, “we do not refund deposits…”, and refunded $500. During interviews, both, the complainant as well as the licensee, acknowledged that the amount paid was a “deposit” related to an impending admission at the Residential Care Facility for the Elderly.

Report continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2020
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 14-AS-20201125154138
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: JUDY'S HOMES FOR THE ELDERLY, INC.
FACILITY NUMBER: 415600750
VISIT DATE: 12/07/2020
NARRATIVE
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Section 87507(g)(3)(C)(4) specifies that any fee that is charged prior to or after admission, shall be clearly specified, and also states that a licensee shall not require, request, or accept any funds from a resident or a resident’s representative, if any, that constitutes a deposit against any possible damages by the resident. The only verifiable specification is that the funds paid were for a deposit. Therefore, the licensee accepted funds from a resident or a resident’s representative that constituted a deposit. Based on this information, the deposit needs to be refunded, and since the licensee provided only a partial refund, the allegation that the facility failed to provide a refund is substantiated.

Deficiencies are being cited in accordance to California Code of Regulations, Title 22, Division 6, on the attached LIC 9099D.

An exit interview was conducted. A copy of this report and appeal rights were discussed and emailed to Administrator Mercy Moreira for signature.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 14-AS-20201125154138
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: JUDY'S HOMES FOR THE ELDERLY, INC.
FACILITY NUMBER: 415600750
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/10/2020
Section Cited
CCR
87507(g)(3)(C)(4)
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87507 Admission Agreements: (g) Admission agreements shall specify the following: (3)Payment provisions, including the following: (C)Any fee that is charged prior to or after admission, shall be clearly specified. (4)A licensee shall not require, request, or accept any funds from a resident or a resident’s representative, if any, that constitutes a deposit against any possible damages by the resident. This requirement is not met as evidenced by:
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Licensee has agreed to give a full refund back to complainant by POC due date which is 12/10/20. Licensee will send LPA a picture of the refunded check issued.
Failure to correct this deficiency by due date may result in a civil penalty of $100 or more per day.
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Based on obersavtion and interviews, the licensee did not ensure the fee was clearly specified in the admission agreement.
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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: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3