435202780-6-22-2022-26-AS-SYIP-CFNTTB-20220623150029

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202780
Report Date: 06/22/2022
Date Signed: 06/22/2022 04:45:50 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, 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
03/09/2022 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20220309173509

FACILITY NAME:	SONNET HILL		FACILITY NUMBER:	435202780
ADMINISTRATOR:	HAHKLOTUBBE, DAVID		FACILITY TYPE:	740
ADDRESS:	429 MERIDIAN AVE		TELEPHONE:	(408) 731-0019
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95126
CAPACITY:	80	CENSUS: 17	DATE:	06/22/2022
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Jasmine Latu		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Resident is being overcharged.
Authorized representative was not provided an itemized list of fees.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Jasmine Latu.

On 03/09/2022, the Department received a complaint with the above allegations. The Department conducted facility visits on 03/18/2022 and 06/02/2022. The Department interviewed 6 staff plus the Administrator (Admin). The Department also conducted interviews with 5 responsible parties of residents. The Department obtained copies of resident records and communications between the facility staff and resident R1’s responsible person (RP1).

See LIC9099-C for more information. Page 1 of 3.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022

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-20220309173509

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SONNET HILL	FACILITY NUMBER: 435202780
	VISIT DATE: 06/22/2022

NARRATIVE

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RP1 states that the facility did not provide an admission agreement for R1 when R1 was first being admitted into the facility. RP1 states that the only document that the facility had RP1 sign was the Reservation Agreement, which is dated 07/30/2021. The Reservation Agreement states that R1’s monthly charge does not include incontinence care and support product. It states the amount charged for the incontinence care and support product will be determined by the service plan at the time of physical occupancy of the living unit.

R1’s Physician’s Report (LIC 602) dated 09/28/2021 states R1 has bowel and bladder impairment and has incontinence.

R1’s Sonnet Hill Resident Evaluation form dated 10/05/2021 indicates that R1, “requires full assistance to manage continence; is routinely incontinent of bowel/bladder, requires regular cleaning and changing of undergarments and bedding.” During interview, staff S1 stated that RP1 was present with S1 during R1’s assessment at another facility. S1 stated RP1 was provided with a copy of the assessment during the care plan meeting.

R1’s Appraisal/Needs and Services Plan indicates R1’s move-in date is 10/05/2021.

During interview, Administrator (ADM) stated to have mistakenly given RP1 the original admission agreement because RP1 stated to have wanted to review the admission agreement closely. ADM states to have asked RP1 to return the Admission Agreement, but RP1 never returned it.

In email correspondences, ADM told RP1 that RP1 had taken the original Admission Agreement and it was never returned. RP1 responded to ADM that RP1 only had a copy and did not take the original. ADM stated to RP1 that the facility has taken accountability for not addressing the incontinence care in the initial contract and is willing to absorb the loss for the two months of October and November 2021. ADM stated the facility would like to begin charging RP1 for incontinence care going forward, to which RP1 responded that RP1 did not agree to the extra charge.

See LIC9099-C for more information. Page 2 of 3.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20220309173509

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SONNET HILL	FACILITY NUMBER: 435202780
	VISIT DATE: 06/22/2022

NARRATIVE

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RP1 confirmed to only have had a copy of the Reservation Agreement, not the Admission Agreement. A copy of the Reservation Agreement dated 7/30/2021 was obtained and reviewed and noted the charge for incontinent care was not listed.

There were numerous email communications between RP1 and Admin on the charges, but no admission agreement was ever completed to list the charges.

The facility failed to provide RP1 with an itemized list of fees upon initial admission to the facility, which resulted in RP1 not being told that R1 would be charged for incontinence care. Although the facility told RP1 that incontinence care would be an additional charge if RP1 was incontinent and RP1’s Resident Evaluation states RP1 is fully incontinent, ADM admits in email correspondence to RP1 that the facility did not include the incontinence care charges in the initial contract.

No new admission agreement was completed upon knowledge of the mistake in the initial contract.

Based on records review and interviews, there is preponderance of evidence to prove the alleged violations did occur; therefore, the allegations are substantiated.

Deficiencies were cited as per California Code of Regulations Title 22. See LIC9099-D for more information.

This report was reviewed with Jasmine Latu and a copy of the reports and appeal rights were provided.

Page 3 of 3.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20220309173509

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SONNET HILL	FACILITY NUMBER: 435202780
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/22/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/29/2022 Section Cited CCR 87507(g)(3)(B)(2)	1 2 3 4 5 6 7	87507 Admission Agreements (g)(3)(B)(2): (g) Admission agreements shall specify the following: (3) Payment provisions, including the following: (B) Rate for additional items and services, including: 2. A separate charge for an item or service may be assessed only if that charge is included in and authorized by the admission agreement	1 2 3 4 5 6 7	Licensee agrees to train relevant staff on signing and completing admission agreement and all intake forms at the time of admission. Once training is completed, the Licensee agrees to submit copies of the training records to CCLD.
	8 9 10 11 12 13 14	This requirement is not being met as evidenced by: Based on interview and record review, facility failed to complete the admission agreement for R1 during the entire time of admission. Without the admission agreement, the separate charge for incontinent care was not authorized due to lack of admission agreement. This poses a potential risk to the health and safety of the resident in care.	8 9 10 11 12 13 14
Type B 06/29/2022 Section Cited CCR 87468.2(a)(12)	1 2 3 4 5 6 7	87468.2(a)(12) Additional Personal Rights of Residents in Privately Operated Facilities: (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (12) To receive in the admission agreement a comprehensive description of the method for evaluating residents’ service needs and the fee schedule for the items and services, and to receive written notice of any rate increases according to Health and Safety Code sections 1569.655 and 1569.884.	1 2 3 4 5 6 7	Licensee agrees to train relevant staff on providing newly admitted residents with a fee schedule for the items and services for which the resident will be charged. Once training is completed, the Licensee agrees to submit copies of the training records to CCLD.
	8 9 10 11 12 13 14	This requirement is not being met as evidenced by: Based on interview and record review, R1 was not given a copy of admission agreement that listed the fee schedule but a reservation agreement which did not list the fee for incontinent care. This poses a potential risk to the health and welfare of the resident in care.	8 9 10 11 12 13 14

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: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022

LIC9099 (FAS) - (06/04)

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