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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600855
Report Date: 03/17/2025
Date Signed: 03/17/2025 04:49:28 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
03/11/2025 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250311150516
FACILITY NAME:ARAVILLE RESIDENTIAL CARE HOME IIFACILITY NUMBER:
415600855
ADMINISTRATOR:PANIZA, DORIEFACILITY TYPE:
740
ADDRESS:1136 VERMONT AVENUETELEPHONE:
(650) 799-5722
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:6CENSUS: 6DATE:
03/17/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Caregiver, Mila De VillaTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Licensee did not provide a refund upon resident's death
INVESTIGATION FINDINGS:
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On March 17, 2025 Licensing Program Analyst (LPA) Murial Han conducted an unannounced 10-day complaint investigation. LPA met with caregiver, Mila De Villa and explained the purpose of today's visit. Caregiver called and informed manager, Amie Flores of LPA's visit.

Regarding to the allegation of- licensee did not provide a refund upon resident's death, the reporting party stated that resident-in-question (R1) passed away on 12/25/2024 and the responsible party has not gotten the refund.

During today's visit, LPA interviewed the manager over the phone and she stated that the Licensee's son is handling the refund and he is planning to refund the money this month. LPA reminded the manager that per Title 22, the refund shall be issued within 15 days after the personal property is removed.

After the investigation, this allegation is substantiated.

Based on interview, during the investigation, the preponderance of evidence standard has been met. Therefore, this allegation was determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

Report was discussed with caregiver and a copy is provided with Appeal Rights.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2025
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 14-AS-20250311150516
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: ARAVILLE RESIDENTIAL CARE HOME II
FACILITY NUMBER: 415600855
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/24/2025
Section Cited
HSC
1569.652(c)
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Health and Safety Code section 1569.652 provides in part:..(c) A refund of any fees paid in advance covering.. within 15 days after the personal property is removed. This requirement is not met as

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The administrator/licensee shall review the regulation and provide a statement in writing acknowledging the review and provide a copy of proof that the refund was issued. The administrator/licensee will provide a
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evicenced by based on interivew, R1 passed away on 12/25/24 and the refund has yet been issued which poses a potential health and safety risk with residents in care.
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copy of the proof and the written statement to CCL by 3/25/2025.
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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: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2