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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435200694
Report Date: 11/27/2024
Date Signed: 11/27/2024 03:28:17 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/09/2024 and conducted by Evaluator Simranjit Rai
COMPLAINT CONTROL NUMBER: 26-AS-20240809150511
FACILITY NAME:SUNRISE MANOR IIFACILITY NUMBER:
435200694
ADMINISTRATOR:AIDA MIRANDAFACILITY TYPE:
740
ADDRESS:2536 AUSTIN PLACETELEPHONE:
(408) 249-1149
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY:0CENSUS: 5DATE:
11/27/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Lead Staf, Maylinda SorianoTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff not providing a refund upon resident’s death.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with Lead Staf, Maylinda Soriano and stated the purpose of today’s visit. Lead Staff notified Licensee/Administrator Aida Miranda of LPAs' visit and stated Licensee/Administrator was not available at the time and unable to be present during today's visit.

On 8/9/2024, the Department received a complaint with the above allegation. It was alleged resident R1 passed away on January 9th, 2023, under Hospice services. R1 had two financial responsible parties who automatically mailed checks to the facility to pay for R1’s rent invoice.

Continuation on LIC 9099-C, Page 1 of 2.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2024
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 4
Control Number 26-AS-20240809150511
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: SUNRISE MANOR II
FACILITY NUMBER: 435200694
VISIT DATE: 11/27/2024
NARRATIVE
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Page 2 of 2.

Based on investigation interview with staff (S1), S1 stated he/she is responsible to depositing rent checks to the bank account when received through mail. S1 stated facility policy was to refund rent money after resident’s personal items have been removed from the room. S1 stated resident’s person items were not removed from the facility and facility staff disposed of the items in April or May when the city conducted the annual clean up. S1 stated the facility ended R1’s financial responsibility on 1/31/2023 but no written notice was provided to R1’s financial responsible party. S1 admitted that R1 checks were mailed to the facility after R1’s Death from February 2023 to October 2023 and were deposited into facility’s account and refund was not provided.

LPA Rai reviewed R1’s Admission Agreement under Refund Policy signed and dated on 11/19/2020 which stated on page 2 “In the event of death, refund will be pro-rated based on the number of days used”.

Based on review of R1’s financial statements, there were 10 checks paid by one out of two financial responsible party which were deposited to the facility account. R1’s monthly rent which was paid by the financial party was $1,163.77. The total amount paid by R1’s the financial responsible party from February 2023 to October 2023 was $10,493.93.

Based on interviews and observation/inspection of the facility, the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D.

This report was reviewed with Administrator and a copy of the report was provided. Appeal Rights was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 26-AS-20240809150511
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SUNRISE MANOR II
FACILITY NUMBER: 435200694
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/28/2024
Section Cited
HSC
1569.652(a)
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1569.652 (a)...No fees shall accrue once all personal property belonging to the deceased resident is removed from the living unit.

This requirement was not met as evidenced by:
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Licensee/Administrator was not available during today's visit. Licensee/Administrator to submit a written plan of action and understanding of Title 22 regulations by POC due date.
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Based on interview and record review, resident R1 was accruing rent after R1 passed away 1/9/2023 and Licensee continued to deposit the rent checks after 1/9/2023 which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.
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Type A
11/28/2024
Section Cited
HSC
1568.082(3)
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1568.082 Suspension or revocation of licensees...(3) Conduct which is inimical to the health, welfare or safety of either an individual in or receiving services from the facility...
This requirement is not met as evidenced by:
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Licensee/Administrator was not available during today's visit. Licensee/Administrator to submit a written statement of his/her understanding of the regulation regarding conduct inimical by POC due date.
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Based on interview and record review, Licensee/Administrator committed inimical conduct that involved financial abuse of R1 by depositing rent checks for 9 months after R1 passed away which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.
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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: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 26-AS-20240809150511
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SUNRISE MANOR II
FACILITY NUMBER: 435200694
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/28/2024
Section Cited
CCR
87405(d)(3)
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87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications...(3) Ability to maintain or supervise the maintenance of financial and other records.
This requirement was not met as evidenced by:
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Licensee/Administrator was not available during today's visit. Licensee/Administrator to submit a written plan of action and understanding of Title 22 regulations by POC due date.
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Based on interview and record review, Licensee/Administrator did not maintain or supervise the financial records for R1 wherein Licensee/Administrator was depositing rent checks for 9 months after R1 passed away on 1/9/2023 which poses/posed an immediate Health,
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(con't) Safety, or Personal Rights risk to persons in care.
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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: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4