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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002764
Report Date: 03/08/2023
Date Signed: 03/08/2023 03:00:27 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/07/2023 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20230307081924
FACILITY NAME:SAINT LORENZ ASSISTED LIVINGFACILITY NUMBER:
455002764
ADMINISTRATOR:BIRD, JAMESFACILITY TYPE:
740
ADDRESS:740 LAKE BLVDTELEPHONE:
(650) 632-5300
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:17CENSUS: 17DATE:
03/08/2023
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Jenesy EdelmanTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Licensee did not refund responsible party after resident's death
INVESTIGATION FINDINGS:
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LPA Hiratsuka conducted this unannounced complaint visit. LPA wore a surgical mask and observed all staff wearing one.

LPA investigated the allegation above. LPA interviewed Jenesy Edelman, Administrative Assistant, and Shirl Freeman, Facility Manager, and reviewed the admission agreement. The admission agreement does have the clause that a refund shall be issued when a resident dies and after all personal belongings are removed. California Health and Safety Code §1569.652 Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds does state a refund shall be issued when a resident dies after all personal belongings have been moved out. LPA was also informed the room has been occupied by a new resident since.


Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023
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 3
Control Number 59-AS-20230307081924
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: SAINT LORENZ ASSISTED LIVING
FACILITY NUMBER: 455002764
VISIT DATE: 03/08/2023
NARRATIVE
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Based on the above, the allegation is substantiated. A copy of the CA health and safety section was left with Administrative Assistant.


Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code. Failure to correct shall result in civil penalties. appeal rights left
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20230307081924
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: SAINT LORENZ ASSISTED LIVING
FACILITY NUMBER: 455002764
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
03/29/2023
Section Cited
HSC
1569.652(a)
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A residential care facility for the elderly shall not require advance notice for terminating an admission agreement upon the death of a resident. No fees shall accrue once all personal property belonging to the deceased resident is removed from the living unit
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By 03/29/2023, Licensee shall submit a written plan of correction on how he shall ensure refunds are issued correctly to the estate of deceased residents.
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This requirement is not met as evidenced by: Based on interview with Complainant and Administrative Assistant a refund has not been issued. This does not pose an immediate risk to residents.
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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: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3