496801409-5-12-2021-21-AS-BMOS-C35R4M-20210518124147

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496801409
Report Date: 05/12/2021
Date Signed: 05/12/2021 11:21:14 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/03/2021 and conducted by Evaluator David Leibert

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20210503163002

FACILITY NAME:	ANSON PLACE RESIDENTIAL CARE HOME		FACILITY NUMBER:	496801409
ADMINISTRATOR:	DIMAPILIS, DANILO		FACILITY TYPE:	740
ADDRESS:	5926 ANSON DR.		TELEPHONE:	(707) 538-4988
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95409
CAPACITY:	6	CENSUS: 1	DATE:	05/12/2021
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Danillo Dimapilis		TIME COMPLETED:	08:23 AM

ALLEGATION(S):

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Licensee did not refund fees paid in advance which were due when resident's personal belongings were removed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst Leibert met with Administrator Dimapilis this date for the purpose of delivering findings on this complaint. The visit was conducted via tele-visit due to the Covid-19 precautions. This Department has taken statements from the parties and reviewed documents in the course of this investigation. The following determinations have been made: R1 resided for a short period at the facility and died while in placement on May 26, 2019; A refund of prepaid fees was due the estate upon the removal of R1's belongings; Complainant alleges that the refund was not paid; Administrator admits that the refund was not paid and has agreed to pay the refund forthwith. Based upon the statements made and documents reviewed, the preponderance of evidence standard has been met. Therefore, the allegation is 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.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021

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 21-AS-20210503163002

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: ANSON PLACE RESIDENTIAL CARE HOME	FACILITY NUMBER: 496801409
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/12/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/19/2021 Section Cited HSC 1569.652(c)	1 2 3 4 5 6 7	HSC 1569.652(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.	1 2 3 4 5 6 7	Administrator shall refund the estate of R1 in the amount of $4212.00 by POC date and will submit proof of payment to CCL by POC date in order to clear the deficiency.
	8 9 10 11 12 13 14	****Based upon statements made and documents reviewed, this requirement has not been met as evidenced by: Prepaid fees were not refunded following the death of R1 and removal of R1's belongings. This posed a potential violation of R1's personal rights.	8 9 10 11 12 13 14
	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: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021

LIC9099 (FAS) - (06/04)

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