425850025-5-30-2023-29-AS-KBUY-CSCQAW-20230531120038

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425850025
Report Date: 05/30/2023
Date Signed: 05/30/2023 10:58:37 AM

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
02/24/2023 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20230224163929

FACILITY NAME:	SANTA MARIA TERRACE		FACILITY NUMBER:	425850025
ADMINISTRATOR:	ENRIQUEZ, SANJUANA		FACILITY TYPE:	740
ADDRESS:	1405 E MAIN ST		TELEPHONE:	(805) 925-8713
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY:	140	CENSUS: 94	DATE:	05/30/2023
		UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Amy Bowman, Wellness Director		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Facility did not issue a correct refund

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Olson conducted an unannounced subsequent complaint visit to issue final findings on the allegations above. LPA requested relevant documents, interviewed reporting party on 3/1/23, interviewed Administrator and Care Staff on 3/2/23, and interviewed Wellness Director on 3/28/23. LPA met with Wellness Director and explained the purpose of the visit.

On the allegation: Facility did not issue a correct refund. It was alleged that there were double charges for tray service and R1 was not issued a correct refund. LPA reviewed R1’s invoices from June 2022 through March 2023 and observed multiple charges, credits, and adjustments. LPA made a spreadsheet with all charges and credits and observed the following: On 7/1/22, $300 was charged for “Tray Charges.” On 7/1/22, there was a second charge of $438 for “Tray Charges” for the same month. No refund was issued for the duplicate charge. On 9/1/22 the facility billed $300 for tray charges as well as another charge for $528 for tray charges on the same day. The $528 charge was refunded on 11/1/22. On 10/1/22, $300 was charged for “Tray Charges”. Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

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 4

Control Number 29-AS-20230224163929

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: SANTA MARIA TERRACE	FACILITY NUMBER: 425850025
	VISIT DATE: 05/30/2023

NARRATIVE

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On 10/26/23 there was a second tray charge of $546. No refund was issued for the duplicate charge.

Administrator stated there is a flat fee for tray service. Administrator issued a refund to R1 for the double charges on 4/24/23 for $987, after the initial complaint visit. Based on the information obtained, the allegation, Facility did not issue a correct refund is Substantiated. A Technical Violation is issued because the facility issued a refund.

Exit Interview Conducted, copy of report, and appeal rights was issued via email and printed.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
02/24/2023 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20230224163929

FACILITY NAME:	SANTA MARIA TERRACE		FACILITY NUMBER:	425850025
ADMINISTRATOR:	ENRIQUEZ, SANJUANA		FACILITY TYPE:	740
ADDRESS:	1405 E MAIN ST		TELEPHONE:	(805) 925-8713
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY:	140	CENSUS: 94	DATE:	05/30/2023
		UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Amy Bowman, Wellness Director		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Facility charged resident for services not needed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Olson conducted an unannounced subsequent complaint visit to issue final findings on the allegations above. LPA requested relevant documents, interviewed reporting party on 3/1/23, interviewed Administrator and Care Staff on 3/2/23, and interviewed Wellness Director on 3/28/23. LPA met with Wellness Director and explained the purpose of the visit.

On the allegation: Facility charged resident for services not needed. It was alleged that the facility charged the resident for incontinence care and shower assistance when it wasn’t needed. Interview with Wellness Director revealed that R1’s assessment indicated they may need help with changing their brief and assistance to the toilet and/or showers. R1 moved into the facility after living at home and had recently had a fall as well as kidney problems. The facility decided to try incontinence care and shower assistance to ensure R1 got the care they needed. Wellness Director stated Incontinence care was initiated on 6/6/22 and discontinued on 6/23/22.
Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20230224163929

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: SANTA MARIA TERRACE	FACILITY NUMBER: 425850025
	VISIT DATE: 05/30/2023

NARRATIVE

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Interviews with care staff revealed that they would check on (R1) every 2 hours but stated R1 was mostly independent and rarely needed assistance with incontinence care. LPA asked Wellness Director why staff continued to check on R1 even after incontinence care was removed from the care plan. Wellness Director stated that all new residents get Wellness Checks and Escort Service added to their plan free of charge for the first week. Wellness Director stated that the Wellness Checks and Escort Service were not removed until 11/23/22. LPA reviewed R1’s Physician’s Report dated 5/9/22 which states resident has bowel and bladder impairment, and notes say “incontinence/Depends”. “Able to care for own toileting need” is not checked yes or no, but under notes states: “may need assist with transfer.” LPA reviewed facility invoices and observed R1 was charged full price ($450) for incontinence care for June and July 2022 but was later refunded and only charged a total of $285 for the dates between 6/6/22 and 6/23/22. LPA also observed R1 was charged $90 in June and $300 in July for shower assistance but later refunded and only charged a total of $10. Due to the needs listed on the physician’s report, the facility charged R1 for the assistance given between 6/6/22-6/23/22 while determining the resident’s real needs. The facility stopped charging for services not needed and refunded a proportional amount to R1. Based on the information obtained, the allegation, Facility charged resident for services not needed, is unsubstantiated at this time.

Exit interview conducted, copy of report was printed and emailed.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

LIC9099 (FAS) - (06/04)

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