496803632-2-16-2021-21-AS-CMAZ-BYQPPA-20210302102912

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803632
Report Date: 02/12/2021
Date Signed: 02/16/2021 02:40:34 PM

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
12/31/2020 and conducted by Evaluator Kimberley Mota

COMPLAINT CONTROL NUMBER: 21-AS-20201231103013

FACILITY NAME:	SERENITY BOARD AND CARE		FACILITY NUMBER:	496803632
ADMINISTRATOR:	TRINIDAD, JOEL		FACILITY TYPE:	740
ADDRESS:	407 CALISTOGA ROAD		TELEPHONE:	(707) 537-1933
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95409
CAPACITY:	6	CENSUS: 6	DATE:	02/12/2021
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Joel Trainidad, Licensee		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility failed to provide a refund upon resident’s death

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mota met with Joel Trinidad, Licensee via tele visit in order to deliver findings regarding the above-mentioned complaint allegation.

During the investigation LPA conducted interviews. Complainant alleged that after resident, R1 passed away on 12/21/20, R1's personal belongings were removed from the facility on 12/22/2020 and 12/24/2020, but they were not issued a refund. Facility stated due to an increase in care, a refund of remaining monies did not apply. Facility determined that their allegation was not supported and issued a refund check on 1/6/2021 which was within the 15 days required by regulation.

This agency has investigated the complaint alleging facility failed to provide a refund upon resident’s death. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5079
LICENSING EVALUATOR NAME: Kimberley Mota	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2021

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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