496803737-4-15-2022-21-AS-KMOA-CDPRVM-20220421132146

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803737
Report Date: 04/15/2022
Date Signed: 04/15/2022 02:34:21 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
02/22/2022 and conducted by Evaluator Erik Gonzalez Campos

COMPLAINT CONTROL NUMBER: 21-AS-20220222103040

FACILITY NAME:	SUNRISE VILLA SANTA ROSA		FACILITY NUMBER:	496803737
ADMINISTRATOR:	OLSON, KATHLEEN		FACILITY TYPE:	740
ADDRESS:	4225 WAYVERN DR		TELEPHONE:	(707) 538-2590
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95409
CAPACITY:	114	CENSUS: 64	DATE:	04/15/2022
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Health Services Director, Teresa Weerts		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Admissions Agreement was not adhered to

INVESTIGATION FINDINGS:

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The Department conducted a complaint investigation regarding the allegation listed above. Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 04/15/2022 to delivering findings for the above allegation. LPA met with Teresa Weerts, Health Services Director.

There is an allegation of admission agreement was not adhered to. During initial complaint inspection on 03/02/2022, LPA received a copy of admission agreement for Resident 1 (R1). Admission agreement was signed by facility representative and R1’s representative on 09/05/2021. Admission agreement states that agreement will automatically terminate upon death of a resident. Furthermore, resident representative will receive a refund for any fees paid in advance within 15 days of removal of resident’s personal property. Interviews with Reporting Party (RP), health services director and business office manager revealed that apartment was vacant and empty on 12/10/2022.

Continued on LIC 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022

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

Control Number 21-AS-20220222103040

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: SUNRISE VILLA SANTA ROSA	FACILITY NUMBER: 496803737
	VISIT DATE: 04/15/2022

NARRATIVE

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Facility provided LPA with final account statement dated 12/16/2021. Final account statement reflected a refund of $3,673.81 based upon a move out date of 12/15/2021. RP stated to LPA that they requested the facility correct the refund amount to be based upon a move out date of 12/10/2022. Final account statement provided by facility dated 01/28/2022 shows an additional credit of $1,148.05 for a total refund of $4,821.86. LPA obtained a copy of the check for $4,821.86 dated 02/11/2022. Responsible parties received refund after the 15 days the admission agreement states they would. Based upon LPA record review and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022

LIC9099 (FAS) - (06/04)

Page: 2 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
02/22/2022 and conducted by Evaluator Erik Gonzalez Campos

COMPLAINT CONTROL NUMBER: 21-AS-20220222103040

FACILITY NAME:	SUNRISE VILLA SANTA ROSA		FACILITY NUMBER:	496803737
ADMINISTRATOR:	OLSON, KATHLEEN		FACILITY TYPE:	740
ADDRESS:	4225 WAYVERN DR		TELEPHONE:	(707) 538-2590
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95409
CAPACITY:	114	CENSUS: 64	DATE:	04/15/2022
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Health Services Director, Teresa Weerts		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Resident Representative's requests for communication were not responded to in a timely manner

INVESTIGATION FINDINGS:

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The Department conducted a complaint investigation regarding the allegations listed above. Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 04/15/2022 to delivering findings for the above allegation. LPA met with Teresa Weerts, Health Services Director.

There is an allegation of resident representative's requests for communication were not responded to in a timely manner. Reporting Party (RP) stated they requested facility correct refund amount after initially being credited the incorrect amount. Record Review revealed that final account statement was edited to reflect correct refund amount on 01/28/2022. RP stated they received check on 02/22/2022, check was dated 02/11/2022. Although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violation did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED.

Exit interview conducted with Teresa Weerts and a copy of this report printed for the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 21-AS-20220222103040

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: SUNRISE VILLA SANTA ROSA	FACILITY NUMBER: 496803737
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/15/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/22/2022 Section Cited HSC 1569.652	1 2 3 4 5 6 7	HSC-1569.652 Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds. (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,	1 2 3 4 5 6 7	Facility has since reimbursed responsible party. Deficiency is cleared.
	8 9 10 11 12 13 14	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. Licensee did not meet the requirement as evidenced by documents and interviews indicating that facilty did not reimburse deceased resident's responsible party within 15 days.	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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022

LIC9099 (FAS) - (06/04)

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