435294206-6-30-2020-26-AS-RMAO-BRDS4W-20200710133322

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294206
Report Date: 06/25/2020
Date Signed: 06/30/2020 09:28:53 AM

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
02/26/2020 and conducted by Evaluator Karen Taku

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20200226153807

FACILITY NAME:	KIMBERLY'S ELDER KARE KOTTAGE		FACILITY NUMBER:	435294206
ADMINISTRATOR:	KENDALL HALL		FACILITY TYPE:	740
ADDRESS:	2770 MOORPARK AVENUE		TELEPHONE:	(408) 483-2433
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95128
CAPACITY:	6	CENSUS:	DATE:	06/25/2020
		UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Debra Hall		TIME COMPLETED:	04:55 PM

ALLEGATION(S):

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Facility failed to issue proper refund

INVESTIGATION FINDINGS:

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On June 25, 2020, Licensing Program Analyst (LPA) Karen Taku conducted an unannounced Complaint Tele-visit, to deliver complaint investigation findings. Due to COVID19 preventative measures, on-site visits have been suspended. LPA spoke with Licensee Debra Hall. (Census: 6)

On March 6, 2020, Community Care Licensing Division – Adult and Senior Program (CCLD-ASP) received a complaint against Kimberly’s Elder Kare Kottage. The Reporting Party (RP) alleges, the facility failed to issue a proper refund.

On March 6, 2020, Licensing Program Analyst (LPA) Karen Taku and Licensing Program Manager (LPM) Romeo Manzano conducted an initial 10-Day Compliant visit and met with the Administrator. LPA interviewed staff, reviewed and obtained copies of R1 records including, but not limited to, admission agreement, emergency contact information, physician’s report, appraisal needs and services plan, death report, and outside hospice agency reports.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Karen Taku	TELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2020

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 26-AS-20200226153807

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: KIMBERLY'S ELDER KARE KOTTAGE	FACILITY NUMBER: 435294206
	VISIT DATE: 06/25/2020

NARRATIVE

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Allegation #1 Facility Failed to issue proper refund

On March 6, 2020, LPA reviewed R1’s admission agreement. Based on R1’s admission agreement, R1 was admitted to the facility on 9/24/2017, to 11/16/2018. Rent payments are calculated from the 24^th of each month, to the 23^rd of the following month. R1 passed away on 11/16/2018 and personal belongings were removed from the facility on 11/18/2018. Being that rent was paid on 10/24/2018 according to the Admissions Agreement, a refund was prorated for five days. (11/19/2018-11/23/2018)

According to the admissions agreement, “after the death of a resident, the agreement remains in effect and payment is owed until all personal belongings are removed from the premises. Any rent monies paid in advance will be prorated and/or itemized with the balance returned to the responsible person within 30 days.”

Two out of three staff stated, according to the admission agreement, R1 was issued the correct refund for the period of 11/19/2018-11/23/2018.

One out of three staff stated, admission and finances are handled by the Administrator Debra Hall.

LPA obtained a copy of the refund check issued from the facility, and R1’s responsible party confirmed receipt of the check. Reporting party agreed that the refund amount is correct, when calculated from the 24^th of the month per the admission date, rather than the 1^st of the month.”

The Department has investigated the above complaint, alleging the facility failed to issue the proper refund. Based on interviews and review of facility records, DSS-CCLD have found that the complaint allegation is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

No deficiencies cited. The amended report was reviewed with the Licensee and a copy was provided via email for signature.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Karen Taku	TELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2020

LIC9099 (FAS) - (06/04)

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