425801403-4-10-2024-29-AS-KBUY-D5GTLG-20240521144932

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425801403
Report Date: 04/10/2024
Date Signed: 04/10/2024 01:54:02 PM

Substantiated

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
04/10/2024 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20240410112611

FACILITY NAME:	ALEJANDRO'S RCFE		FACILITY NUMBER:	425801403
ADMINISTRATOR:	VENIER D. ALEJANDRO		FACILITY TYPE:	740
ADDRESS:	1130 GRAPEVINE ROAD		TELEPHONE:	(805) 349-9446
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY:	6	CENSUS: 3	DATE:	04/10/2024
		UNANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	Venier D. Alejandro, Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff did not issue a refund to the party that paid the rent

INVESTIGATION FINDINGS:

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Licensing Program Analyst's (LPA's) De Leon and Rankin conducted a 10-day Complaint visit to the facility above. LPA met with Venier D. Alejandro, Administrator and explained the purpose of the visit.

LPA interviewed witness 1 (W1) on 04/09/2024 at 1:35pm. LPA interviewed staff 1(S1) and staff 2 (S2) around 12:00pm on 04/10/2024. LPA requested the following records: Resident 1's (R1's) Incident & Death Reports, Admission Agreement, Pre-Placement Apprisal, ID & Emergency Information, and Resident Personal Property and Valuables and Discharge Paperwork from Marian Regional Medical Center.

On the allegation: Staff did not issue a refund to the party that paid the rent. LPA conducted interviews with staff and witness regarding the facility not issuing a refund to the responsible party (RP) of R1.

Continued 9099-C

Substantiated

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: 04/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

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 5

Control Number 29-AS-20240410112611

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: ALEJANDRO'S RCFE	FACILITY NUMBER: 425801403
	VISIT DATE: 04/10/2024

NARRATIVE

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Administrator did not issue a refund of the rent paid after the death of the resident due to charging R1 for optional items and services for Hospice fees. Administrator did not understand that Hospice fees were not written in the admission agreement (AA) or an addendum to the AA to be able to charge these optional items and services to R1. Administrator agreed to issue a refund to R1's RP. The RP paid rent for March 2024 in the amount of $3700.00. R1 passed away and belongings were packed up from R1's room on 03/07/2024. The facility owes the RP a refund for 24 days at a daily rate of $119.35 per day for a total amount of $2864.40. Based on the evidence this allegation is deemed Substantiated at this time.

Exit interview conducted, deficiency cited, copy of report and appeal rights printed for Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 29-AS-20240410112611

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: ALEJANDRO'S RCFE	FACILITY NUMBER: 425801403
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/10/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/17/2024 Section Cited CCR 87507(5)(A)(1)	1 2 3 4 5 6 7	(5) Refund conditions.(A)...refund for advanced monthly fees will be returned in the event of a resident’s death, ... the resident’s responsible person or other individual or individuals as identified in the admission agreement. This is evidenced by:	1 2 3 4 5 6 7	Administrator agreed to issue refund to RP within 7 days and provide a copy of the check to LPA.
	8 9 10 11 12 13 14	Based on interviews the Licensee did not comply with the regulation above a refund was not issued to R1's RP which poses a potential personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
04/10/2024 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20240410112611

FACILITY NAME:	ALEJANDRO'S RCFE		FACILITY NUMBER:	425801403
ADMINISTRATOR:	VENIER D. ALEJANDRO		FACILITY TYPE:	740
ADDRESS:	1130 GRAPEVINE ROAD		TELEPHONE:	(805) 349-9446
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY:	6	CENSUS: 3	DATE:	04/10/2024
		UNANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	Venier D. Alejandro, Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff did not report a resident death to Licensing
Staff did not safeguard resident personal belongings

INVESTIGATION FINDINGS:

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Licensing Program Analyst's (LPA's) De Leon and Rankin conducted a 10-day Complaint visit to the facility above. LPA met with Venier D. Alejandro, Administrator.

LPA interviewed witness 1 (W1) on 04/09/2024 at 1:35pm. LPA interviewed staff 1(S1) and staff 2 (S2) around 12:00pm on 04/10/2024. LPA requested the following records: Resident 1's (R1's) Incident & Death Reports, Admission Agreement, Pre-Placement Appraisal, ID & Emergency Information, and Resident Personal Property and Valuables and Discharge Paperwork from Marian Regional Medical Center.

On the allegation: Staff did not report a resident death to Licensing. Based on the record review the facility sent Community Care Licensing (CCL) a death report for R1 on 03/07/2024. CCL has a copy of the report on file. Therefore, the allegation is deemed Unsubstantiated at this time.

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: 04/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 29-AS-20240410112611

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: ALEJANDRO'S RCFE	FACILITY NUMBER: 425801403
	VISIT DATE: 04/10/2024

NARRATIVE

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On the allegation: Staff did not safeguard resident personal belongings. LPA interviewed staff and witness which revealed on 03/08/2024 RP came to the facility and asked about R1's belongings but was unable to pick them up at that time. Due to R1 not having next of kin upon death the Santa Barbara Public Administrator was involved and the facility kept all R1's belongings waiting for someone to pick up and no one ever came to the facility to pick them up. R1's personal belongings were still at the facility on LPA's visit. Administrator safeguarded R1's belongings and will provide them to RP or Public Administrator for pickup. Based on the evidence this allegation is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report printed for Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 5