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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803499
Report Date: 12/01/2022
Date Signed: 12/01/2022 12:45:17 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
11/22/2022 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20221122162249
FACILITY NAME:SILVER STARFACILITY NUMBER:
496803499
ADMINISTRATOR:KUMAR, AMIFACILITY TYPE:
740
ADDRESS:1966 DENNIS LANETELEPHONE:
(707) 595-3605
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:6CENSUS: 5DATE:
12/01/2022
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Ami Kumar-Licensee/AdministratorTIME COMPLETED:
12:50 PM
ALLEGATION(S):
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Illegal Eviction
INVESTIGATION FINDINGS:
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Licensing Program Analyst(LPA) Dina Alviso conducted a complaint inspection and met with Ami Kumar, Licensee/Administrator, and Janine Sorrenson, Administrator.
LPA reviewed resident records, and obtsined copies. LPA conducted interviews with staff, and other interested parties. The investigation revealed that the Licensee/Administrator didn't provide written 30-day notice of eviction to the resident/responsible party as required by regulation.

Due to the substantiation of the allegation, "Illegal Eviction", deficiency citation will be issued, Eviction Procedures 87224(a)(4), see LIC9099D.
The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited.
Failure to correct deficiencies may result in civil penalties being assessed.
Appeal Rights Given.
Exit interview conducted with the Administrator
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
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 2
Control Number 21-AS-20221122162249
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: SILVER STAR
FACILITY NUMBER: 496803499
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/07/2022
Section Cited
CCR
87224(a)(4)
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87224 Eviction Procedures

(a)The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5)
(4)If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant to Section 87463, and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident.
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Licensee/Administrator to ensure that if evicting a resident that a written 30 day notice of eviction, in compliance with regulation, is provided to resident/responsile party as required.
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This requirement was not met as evidenced by LPA's review of of resident records and interviews with staff. The Licensee/Administrator didn't provide a written 30-day notice of eviction tothe resident/responsible party. Thhis is a personal rights risk to resident(s).
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Licensee to submit written self confirmation of understanding of the regulation 87224. Submit plan of ensuring that the facility will be in compliance with the above reguation as required. POC due 12/7/22.
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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: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2