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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002714
Report Date: 03/07/2024
Date Signed: 03/07/2024 09:41:19 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/25/2024 and conducted by Evaluator Jaynae Boyles
COMPLAINT CONTROL NUMBER: 59-AS-20240125145955
FACILITY NAME:BONHURST ASSISTED LIVING. CORP (HOUSE I)FACILITY NUMBER:
455002714
ADMINISTRATOR:SKEVIG, ANGELINA MANDRIAFACILITY TYPE:
740
ADDRESS:1306 BONHURST DRIVETELEPHONE:
(530) 244-8458
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:6CENSUS: 6DATE:
03/07/2024
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Administrator- Angelina SkevigTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Staff did not return residents wedding ring to authorized representative after residents’ death.
INVESTIGATION FINDINGS:
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03/072024 Licensing Program Analyst (LPA) Jaynae Boyles made an unannounced visit to the facility and met with the Administrator. The purpose of this visit is to deliver the results of a complaint investigation.
During the interview process, the administrator was interviewed.
During the review of records, LPA reviewed the files of one resident (R1), including, admissions agreement, preplacement appraisal, admissions policies, refund policies, house rules, hospice admissions and payment history.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
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 59-AS-20240125145955
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BONHURST ASSISTED LIVING. CORP (HOUSE I)
FACILITY NUMBER: 455002714
VISIT DATE: 03/07/2024
NARRATIVE
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LPA investigated the allegation, “Staff did not return residents wedding ring to authorized representative after residents’ death”. The Administrator reported to the LPA that the wedding ring is still in the facility, stored in the safe. The administrator reported that they have contacted R1 responsible party on several occasions for pick up of the residents’ personal items with no avail. According to the admissions agreement, theft and loss policy was signed by R1 indicated that in the event of a death of a resident the facility will safeguard all personal belongings until turned over to the resident’s family. The administrator is adhering to the facility policy signed by R1 and ensuing the safeguard of these items until the responsible party can pick up R1 items.

This agency has investigated the complaint alleging,” Staff did not return residents wedding ring to authorized representative after residents’ death”. We have found the complaint was UNFOUNDED, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/25/2024 and conducted by Evaluator Jaynae Boyles
COMPLAINT CONTROL NUMBER: 59-AS-20240125145955

FACILITY NAME:BONHURST ASSISTED LIVING. CORP (HOUSE I)FACILITY NUMBER:
455002714
ADMINISTRATOR:SKEVIG, ANGELINA MANDRIAFACILITY TYPE:
740
ADDRESS:1306 BONHURST DRIVETELEPHONE:
(530) 244-8458
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:6CENSUS: 6DATE:
03/07/2024
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Administrator TIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Staff did not refund authorized representative after residents’ death.
INVESTIGATION FINDINGS:
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03/07/2024 Licensing Program Analyst (LPA) Jaynae Boyles made an unannounced visit to the facility and met with the Administrator. The purpose of this visit is to deliver the results of a complaint investigation. During the interview process, the administrator was interviewed.
During the review of records, LPA reviewed the files of one resident (R1), including, admissions agreement, preplacement appraisal, admissions policies, refund policies, house rules, Hospice admissions and payment history. LPA investigated the allegation, “Staff did not refund authorized representative after residents’ death”. The admissions agreement stated that,” refunds will be granted after 30 days notices if Resident is transferring to another facility and after the room has been vacated. In case of death, prorated after the room has been vacated.” The administrator reported an addendum for residents with hospice is completed with the admissions agreement indicating that if a resident is receiving hospice services at the time of death there will be no refund. However, R1 or their responsible party did not sign this addendum.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20240125145955
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BONHURST ASSISTED LIVING. CORP (HOUSE I)
FACILITY NUMBER: 455002714
VISIT DATE: 03/07/2024
NARRATIVE
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LPA was able to determine R1 passed in October 2022 and no refund was issued. In addition, Health and Safety Code §1569.652 states facilities are required to refund responsible party within 15 days of the death of a resident and once their personal belongings have been removed. LPA was able to determine that the personal belongings of the resident have not been returned.
Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. An exit interview was conducted. A copy of the report was provided to the administrator.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 59-AS-20240125145955
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BONHURST ASSISTED LIVING. CORP (HOUSE I)
FACILITY NUMBER: 455002714
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/14/2024
Section Cited
HSC
1569.652(C)
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Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds.
(c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed.
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Administrator agrees to meet with R1's responsible party to review refund amount. Once meeting has taken place Administrator to send LPA the refund amount given to R1's responsible party.
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Based on record review facility did not refund R1's responsible party withing 15 days which poses a potential personal rights risk to residents 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: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5