486803786-2-16-2023-21-AS-KMOA-CQ7STD-20230323140920

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803786
Report Date: 02/14/2023
Date Signed: 02/16/2023 11:31:51 AM

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
09/19/2022 and conducted by Evaluator Araceli Canela

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20220919152649

FACILITY NAME:	ISLES ASSISTED LIVING FACILITY, THE		FACILITY NUMBER:	486803786
ADMINISTRATOR:	EFE, ELENA		FACILITY TYPE:	740
ADDRESS:	129 PACER DR		TELEPHONE:	(707) 254-5444
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	6	CENSUS: 6	DATE:	02/14/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Suzzette Tawzer		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Illegal Eviction

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Araceli Canela arrived unannounced for the purposes of delivering findings and gathering copies of records regarding the above investigation for complaint number 21-AS-20220919152649. LPA toured the facility and made observations.

It was alleged resident R1 received an illegal eviction. R1 sustained a fall, fractured their hip and was sent to a rehabilitation facility after surgery. Investigation revealed, R1 was ready to be discharged and return to the Isles Assisted Living facility. Facility did not issue a lawful legal eviction and expressed to R1's family they were unable to take R1 unless they received a current Physician report and negative Covid test, but also explained they were unable to meet R1's needs as R1 was needing more assistance.
see LIC9099-C for continuation of report

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023

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 5

Control Number 21-AS-20220919152649

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: ISLES ASSISTED LIVING FACILITY, THE	FACILITY NUMBER: 486803786
	VISIT DATE: 02/14/2023

NARRATIVE

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LPA received information, facility spoke with hospital discharge social worker and explained to them, they would not accept R1 back as R1 required more staff to watch R1 all the time, for their safety.
Based on LPA’s record review and statements received, R1 did not receive a Legal eviction, the preponderance of evidence standard has been met, therefore, allegations for, "Illegal Eviction" is found to be SUBSTANTIATED.

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 21-AS-20220919152649

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: ISLES ASSISTED LIVING FACILITY, THE	FACILITY NUMBER: 486803786
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/14/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/21/2023 Section Cited CCR 87224(a)	1 2 3 4 5 6 7	87224(a) Eviction Procedures. The licensee may, upon thirty (30) days written notice to the resident, evict the resident for nonpayment of the rate for basic services, failure to comply with state or local law, failure to comply with the general policies of the facility, development of a need not previously identified, and/or a change of use of the facility.	1 2 3 4 5 6 7	Facility to send in written plan, they understand regulation and how they will ensure they follow it.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: R1 did not receive a proper eviction letter as required. This is a potential risk to the health and safety of residents in care.	8 9 10 11 12 13 14	POC due date 2/21/2023 LPA Araceli Canela
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
09/19/2022 and conducted by Evaluator Araceli Canela

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20220919152649

FACILITY NAME:	ISLES ASSISTED LIVING FACILITY, THE		FACILITY NUMBER:	486803786
ADMINISTRATOR:	EFE, ELENA		FACILITY TYPE:	740
ADDRESS:	129 PACER DR		TELEPHONE:	(707) 254-5444
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	6	CENSUS: 6	DATE:	02/14/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Suzzette Tawzer		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Licensee refused to reimbursed resident's representative
Resident's property was disposed due to sudden eviction.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Araceli Canela arrived unannounced for the purposes of delivering findings and gathering copies of records regarding the above investigation for complaint number 21-AS-20220919152649. LPA toured the facility and made observations.

It was alleged licensee refused to reimburse resident's representative. LPA received information, R1's family paid facility September rent on 9/1/2022 and resident was to return to the facility on 9/16/2022, but because of their change of condition was requirining more care, R1 was not accepted back. Facility reimbursed resident R1's family $3,000.00 and on 9/25/2022, R1's family removed most of their belongings.

See LIC9099-C for continuation of report

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 21-AS-20220919152649

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: ISLES ASSISTED LIVING FACILITY, THE	FACILITY NUMBER: 486803786
	VISIT DATE: 02/14/2023

NARRATIVE

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It was also alleged resident's property was disposed due to sudden eviction. Investigation revealed, residents property was picked up by a company that R1's family hired to pick up items and discard. Facility explained, they informed R1's family they could not accept R1 and they would need to remove their belongings, but did not ask them to throw away. Facility had previously informed R1's family several months before that R1 required more assistance and had issued an eviction to R1. Facility was unable to accept resident back from skilled nursing facility and asked the family to remove R1 belongings.

Although the allegations may be true, or are valid, there is not a preponderance of evidence to prove the alleged violations did, or did not, occur. Therefore, the allegations for Licensee refused to reimbursed resident's representative and Resident's property was disposed due to sudden eviction is UNSUBSTANTIATED.

No citations issued regarding the above allegations.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5