496803807-10-7-2021-21-AS-CMAZ-CABW5B-20220103155851

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803807
Report Date: 10/07/2021
Date Signed: 10/07/2021 05:27:12 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
09/03/2021 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20210903102609

FACILITY NAME:	COGIR OF ROHNERT PARK		FACILITY NUMBER:	496803807
ADMINISTRATOR:	SARINE, STEVE		FACILITY TYPE:	740
ADDRESS:	4855 SNYDER LANE		TELEPHONE:	(707) 585-7878
CITY:	ROHNERT PARK	STATE: CA	ZIP CODE:	94928
CAPACITY:	45	CENSUS:	DATE:	10/07/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Steve Sarine-Administrator		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Resident was not accepted back into the facility after being sent out to the hospital
Resident received an illegal eviction

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

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 6

Control Number 21-AS-20210903102609

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: COGIR OF ROHNERT PARK	FACILITY NUMBER: 496803807
	VISIT DATE: 10/07/2021

NARRATIVE

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R1 was noted to have some bone fractures-rib fractures. Resident was discharged back to the facility on 6/23/21; R1 was sent back out to the hospital ER 6/24/21 due to low oxygen saturation. From 6/24/21, the resident remained hospitalized for needed care, and was discharged to skilled nursing care for rehabilitation needs.

Per interviews with facility staff, and per record reviews, the resident did not receive a written notice of eviction verbally or written; Staff stated they did not give a verbal eviction notice to the resident/responsible party but that there was discussion that the resident should receive skilled nursing care as needed, and would be reassessed prior to discharge from skilled nursing care to ensure residents needs could be met by the facility. Per record review there was no letter of eviction notice in R1's file.

Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegations, Resident was not accepted back into the facility after being sent out to the hospital, Resident received an illegal eviction, are Unsubstantiated. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are Unsubstantiated.
No deficiencies..
Exit interview was conducted

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 6

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
09/03/2021 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20210903102609

FACILITY NAME:	COGIR OF ROHNERT PARK		FACILITY NUMBER:	496803807
ADMINISTRATOR:	SARINE, STEVE		FACILITY TYPE:	740
ADDRESS:	4855 SNYDER LANE		TELEPHONE:	(707) 585-7878
CITY:	ROHNERT PARK	STATE: CA	ZIP CODE:	94928
CAPACITY:	45	CENSUS:	DATE:	10/07/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Steve Sarine-Administrator		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Resident was charged for care fees that were not valid or properly billed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Dina Alviso conducted a complaint inspection, and met with Administrator Steve Sarine, Business Office Manager Tamra Richmond, and Health & Wellness Director Emil DeGuzman . The inspection is being conducted to deliver findings.
The Department interviewed facility staff, S1, S2, and S3, and interviewed other various parties. The Department obtained resident (R1) facility records, including medical records, admission documents, and financial billing records for rent and care fees.
LPA reviewed the financial billing records, including a breakdown of all fees charged. Per record reviews and interviews there were no identified inappropriate charges in the billing; The billing contained no charges for medication management, calls made by the resident, and/or any other fees seen that were charged inappropriately regarding care fees and rental fees..

Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegation, Resident was charged for care fees that were not valid or properly billed, is Unfounded. We have found that the complaint allegation was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
No deficiencies.
Exit interview was conducted.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

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 6

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
09/03/2021 and conducted by Evaluator Dina Alviso

COMPLAINT CONTROL NUMBER: 21-AS-20210903102609

FACILITY NAME:	COGIR OF ROHNERT PARK		FACILITY NUMBER:	496803807
ADMINISTRATOR:	SARINE, STEVE		FACILITY TYPE:	740
ADDRESS:	4855 SNYDER LANE		TELEPHONE:	(707) 585-7878
CITY:	ROHNERT PARK	STATE: CA	ZIP CODE:	94928
CAPACITY:	45	CENSUS:	DATE:	10/07/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Steve Sarine-Administrator		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Due refund owed to the resident/responsible party

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Dina Alviso conducted a complaint inspection, and met with Administrator Steve Sarine, Business Office Manager Tamra Richmond, and Health & Wellness Director Emil DeGuzman . The inspection is being conducted to deliver findings.

The Department interviewed facility staff, S1, S2, and S3, and interviewed other various parties. The Department obtained resident (R1) facility records, including medical records, admission documents, and financial billing records for rent, care fees, and any other charges.
Per records review, and interviews, the investigation revealed that R1/Responsible Party was due a refund. R1 had a refund due in the amount of $2,332.38. R1 's move out date was recorded as physically moved out as of 7/22/2021. Per record reviews and interviews with facility staff, staff requested the due refund on 8/5/2021 and received the check on 9/9/2021
Continued on LIC9099c..

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

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 6

Control Number 21-AS-20210903102609

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: COGIR OF ROHNERT PARK	FACILITY NUMBER: 496803807
	VISIT DATE: 10/07/2021

NARRATIVE

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Per staff, the check was provided to the responsible party; The staff stated that they were aware the refund check should have been provided back to the resident/responsible party sooner than it had been. Staff stated the refund had been requested more than once from the facility's home office. The resident's belongings were out of the facility by 7/22/2021 per record review. Staff stated that they have had a meeting with all parties, and will be refunding an additional amount of $494.76 after discussing care services with the responsible party and agreeing to a refund of monies. This will be provided to the
resident /responsible party as soon as received. At this time the due refund of $2,232.88 has been provided to the responsible party as required.

Based on LPA interviews, and review of information obtained, the investigation has revealed that the allegation of, Due refund owed to the resident/responsible party is ubstantiated.

Due to the substantiation of the allegation, a deficiency will be cited today-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.

Deficiency cited.
Exit interview conducted.
Appeal Rights Given.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 21-AS-20210903102609

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: COGIR OF ROHNERT PARK	FACILITY NUMBER: 496803807
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/07/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/15/2021 Section Cited HSC 1569.652(c)	1 2 3 4 5 6 7	H&S Code- 1569.652(c) Termination of admission agreement upon death of resident; or removal of resident’s property; refund of fees paid; notice of contract termination and refunds. 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	Licensee/Administrator to ensure all due refunds are provided in a timely manner, which would be within law and regulation. Please provide refund policy and procedures of the facility and a written self confirmation of the understanding of refunds due to those that have had terminated contracts and those that have given 30 day notice-ensure
	8 9 10 11 12 13 14	This requirement has not been met based on record reviews, and interviews, The resident had all belongings removed by 7/22/21, and did not receive due refund timely per law and regulations. The refund fee was provided o the resident/responsible party on 9/9/2021. This is a personal rights risk to residents in care.	8 9 10 11 12 13 14	compliance with Health and safety Code. POC due by 10/15/2021.
	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: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

LIC9099 (FAS) - (06/04)

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