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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 480107184
Report Date: 07/29/2022
Date Signed: 07/29/2022 03:11:12 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/30/2022 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-NP-20220330092030
FACILITY NAME:DELTA MEADOWS CARE HOMEFACILITY NUMBER:
480107184
ADMINISTRATOR:CECILIA GANZONFACILITY TYPE:
740
ADDRESS:101 O'BRIEN CIRCLETELEPHONE:
(707) 647-1759
CITY:VALLEJOSTATE: ZIP CODE:
94589
CAPACITY:5CENSUS: 4DATE:
07/29/2022
UNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Cecilia Ganzon, LicenseeTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Resident asked to pay more money for services already covered in admission agreement
INVESTIGATION FINDINGS:
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On 7/29/2022 Licensing Program Analyst (LPA) Tobola conducted a facility visit for the purpose of delivering complaint findings. LPA Tobola toured the facility, gathered facility documents, conducted interviews with staff, residents and outside parties and made observations. LPA A. Canela also conducted initial investigation on 4/8/2022.

Complaint alleges resident (R1) was asked to pay more money for services already covered in admission agreement. Upon review of R1’s admission agreement, it was observed the admission agreement had contradicting information and/or did not specify a fee for transportation to medical appointments. In addition investigation revealed facility care staff (S1) was found providing transportation to R1 at a flat rate fee of $30.00. R1 issued a check to S1 for the $30.00 for services on 2/28/2022 and S1 was notified of an input error when submitting the check to their bank as a deposit for $38.00. S1 received a letter explaining they owed the bank $8.00 as the check cashed was for $30.00 and not $38.00.

Continued onto LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/30/2022 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-NP-20220330092030

FACILITY NAME:DELTA MEADOWS CARE HOMEFACILITY NUMBER:
480107184
ADMINISTRATOR:CECILIA GANZONFACILITY TYPE:
740
ADDRESS:101 O'BRIEN CIRCLETELEPHONE:
(707) 647-1759
CITY:VALLEJOSTATE: ZIP CODE:
94589
CAPACITY:5CENSUS: 4DATE:
07/29/2022
UNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Cecilia Ganzon, LicenseeTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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9
Failure to meet resident needs
INVESTIGATION FINDINGS:
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On 7/29/2022 Licensing Program Analyst (LPA) Tobola conducted a facility visit for the purpose of delivering complaint findings. LPA Tobola toured the facility, gathered facility documents, conducted interviews with staff, residents and outside parties and made observations. LPA A. Canela also conducted initial investigation on 4/8/2022.

Complaint alleges the facility failed to meet resident needs. Based on observations LPA did not see any lack of care from staff towards residents or residents left in a unsanitary or poor state. Based on a review of records interviews with staff and residents (R2, R3 and R4), LPA did not receive any statements of concerns or neglect from the facility staff. Resident R1 was no longer admitted to the facility during LPA's visit for interview and observations. Because of conflicting information the allegation is found to UNSUBSTANTIATED.

A finding that the complaint allegation failure to meet resident needs is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Appeal Rights Given.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022
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 4
Control Number 21-NP-20220330092030
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: DELTA MEADOWS CARE HOME
FACILITY NUMBER: 480107184
VISIT DATE: 07/29/2022
NARRATIVE
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S1 failed to read the statement/letter correctly and informed R1 that they owed them and additional $8.00 because the bank was charging S1. LPA Canela interviewed staff S2 on 4/8/2022 who corroborated to LPA, S1 requested and told R1 they owed them the $8.00 the bank was charging them. S2 also disclosed to LPA they too asked R1, if they would be paying S1 the $8.00. It was also disclosed R1 eventually gave S1 an additional $10.00 but S1 returned the money to R1. On facility visit of 4/8/2022, LPA Canela confirmed with facility Administrator, Cecilia Ganzon, residents pay a flat rate fee of $30.00 for transportation. Based on incomplete information in the admission agreement, the above allegation is found to be SUBSTANTIATED.

The preponderance of evidence standard has been met, therefore the above allegation, resident asked to pay more money for services already covered in admission agreement is SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Appeal Rights Given.

Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-NP-20220330092030
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: DELTA MEADOWS CARE HOME
FACILITY NUMBER: 480107184
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/10/2022
Section Cited
CCR
87507(g)(3)(B)
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87507(g)(3)(B) Admissions Agreement - (g) - Admission agreements shall specify the following: (B) - A comprehensive description of and the corresponding fee schedule for all additional items and services not included in the fees for basic services shall be listed.
**This requirement was not met as evidence by:
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Licensee has immediately stopped receiving additional payments from all residents for transportation services. Licensee agrees to update the admissions agreements for any incoming residents clearly indicating any additional charges to residents if resident choos receive facility transportation services.
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Based on a review of facility and resident records LPA found that facility was charging a flat rate to resident R1 for transportation services which was not clearly indicated in R1's admissions agreement. In addition, upon interviews with staff LPA found that staff S1 had requested for additional money from R1 to compensate for a bank error notification.
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Deficiency cleared at time of visit.
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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.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4