500301453-10-6-2020-27-AS-CACL-BU7VBR-20201008161758

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 500301453
Report Date: 10/05/2020
Date Signed: 10/06/2020 09:46:59 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/09/2019 and conducted by Evaluator Stephenie Doub

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20191209161406

FACILITY NAME:	COVENANT LIVING OF TURLOCK		FACILITY NUMBER:	500301453
ADMINISTRATOR:	CHARLES W. JOHNSON		FACILITY TYPE:	741
ADDRESS:	2125 N OLIVE		TELEPHONE:	(209) 632-9976
CITY:	TURLOCK	STATE: CA	ZIP CODE:	95382
CAPACITY:	377	CENSUS:	DATE:	10/05/2020
		UNANNOUNCED	TIME BEGAN:	03:26 PM
MET WITH:	Ryan Hust, Executive Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Residents in care are being financially abused.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Stephenie Doub contacted the facility on this day to conclued a complaint investigation via telephone due to COVID-19 and pre-cautionary measures. LPA spoke with Executive Director (ED) Ryan Hust and discussed the purpose of the call and the elements of the allegations.

The initial 10-day visit was completed on 12/18/19. The Department investigated the complaint by reviewing documents and e-mails and interviewing witnesses. During the investigation, the Department found the following:
Covenant gathers private financial information from applicants to ensure that they qualify for admission. Covenant’s continuing care contracts with its residents requires them to provide updated private financial information after admission as well. The complainant indicated that Vice President (VP) of Philanthropy with Covenant Living Services instructed the directors of philanthropy at various CLC communities to enter private financial information from residents into a spreadsheet. The Complainant further alleged that financial information was to be gathered to “target” residents to be approached for gifts.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Krystall Moore	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2020

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 27-AS-20191209161406

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: COVENANT LIVING OF TURLOCK	FACILITY NUMBER: 500301453
	VISIT DATE: 10/05/2020

NARRATIVE

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The Department spoke with the VP by phone on April 22, 2020. In that discussion, the VP denied that he had instructed his directors of philanthropy to insert the private financial information of residents into eTapestry, a program CLC and its communities use for donor management or that his directors should compile a spreadsheet of this information. He stated instead that in a November meeting with all the directors of philanthropy of the various CLC communities, he provided the directors with a spreadsheet for discussion purposes only.
The Department reviewed a spreadsheet which called for private financial information from residents including monthly income, real estate, savings/CD, stock holdings, etc. The Department was advised that while the spreadsheet had contained these categories of data from Colorado residents, similar information was never gathered from California residents. The Department has found no evidence that other California communities inserted private financial data in the spreadsheet or eTapestry database. The Department does not know whether the information was provided at the insistence of the VP, but it indisputably was provided for purposes of fundraising.
There is no question that the kind of financial information at issue here is protected by these laws and regulations. Health and Safety Code section 1569.269 entitles residents “to confidential treatment of their records and personal information and to approve their release, except as authorized by law.”” California Code of Regulations, Title 22, Section 87506 subdivision (c) provides that “All information and records obtained from or regarding residents shall be confidential. (1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents. The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative.” Continuing care contract residents enjoy these same rights. (See Health & Safety. Code section 1771.7(a).)
The question is whether the right to confidentiality in these records includes the right not to have private financial data originally gathered from residents for purposes of admission and retention, transferred to corporate fundraisers to use in approaching the residents as donors. Based on interviews, observations and a review of documentation the allegation, “Residents in care are being financially abused” is deemed UNSUBSTANTIATED. The preponderance of evidence standards has not been met.
A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, the preponderance of evidence standards has not been met.
Per California Code of Regulations (CCRs) - Title 22 Division 6 no deficiencies are being cited. An exit interview was conducted with Ryan Hust via telephone and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Krystall Moore	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2020

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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/09/2019 and conducted by Evaluator Stephenie Doub

COMPLAINT CONTROL NUMBER: 27-AS-20191209161406

FACILITY NAME:	COVENANT LIVING OF TURLOCK		FACILITY NUMBER:	500301453
ADMINISTRATOR:	CHARLES W. JOHNSON		FACILITY TYPE:	741
ADDRESS:	2125 N OLIVE		TELEPHONE:	(209) 632-9976
CITY:	TURLOCK	STATE: CA	ZIP CODE:	95382
CAPACITY:	377	CENSUS:	DATE:	10/05/2020
		UNANNOUNCED	TIME BEGAN:	03:26 PM
MET WITH:	Ryan Hust, Executive Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility allowed staff access to resident's financial information without proper consent

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Krystall Moore	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2020

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

Control Number 27-AS-20191209161406

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: COVENANT LIVING OF TURLOCK	FACILITY NUMBER: 500301453
	VISIT DATE: 10/05/2020

NARRATIVE

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In establishing the scope of the resident’s privacy rights, it is important to understand that the residents have privacy rights announced in both federal and state law. (See Health & Safety. Code section 1771.7(a).) Under the Health Insurance Portability and Accountability Act (HIPAA), financial information obtained for purposes of admission is considered “personal health information.” (42 U.S.C. § 1320d(4) and 45 CFR § 160.103 [definition of heath information].) Under HIPPA, a provider of skilled nursing care cannot use personal health information, for purposes other than what it was originally intended without a valid authorization. Consequently, a covered entity, like Covenant, “may not use or disclose protected health information without an authorization that is valid under 45 CFR § 164.508(a)(1). When a covered entity obtains or receives a valid authorization for its use or disclosure of protected health information, such use or disclosure must be consistent with such authorization.” (45 CFR § 164.508(a)(1))

The financial information at issue here is exempt from disclosure under 45 CFR § 164.508(a)(1) and is not subject to the exception found in 45 CFR § 164.514(f)(1). Therefore, absent a valid signed waiver by each resident, the use of the information by fundraisers for the Covenant Benevolence Fund constitutes a violation of HIPAA and Health and Safety Code sections 1569.269 and 1771.7(a) and California Code of Regulations, title 14, section 87506 subdivision (c).

The Department found no evidence that the residents consented to the disclosure. However, the Department has seen documents establishing that private financial information of ten Covenant residents was provided by Ryan Hust to the Covenant Director of Philanthropy. Based on its investigation, the Department has therefore determined that Covenant did access ten residents’ financial information without valid authorization.

The preponderance of evidence standards has been met; therefore, the allegation, “Facility allowed staff access to resident's financial information without proper consent” is found to be SUBSTANTIATED.

A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

SUPERVISOR'S NAME: Krystall Moore	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2020

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20191209161406

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: COVENANT LIVING OF TURLOCK	FACILITY NUMBER: 500301453
	VISIT DATE: 10/05/2020

NARRATIVE

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The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations on the attached 9099D during this visit. The Department shall exercise its authority under H&SC section 1771.7(j) to impose a civil penalty of one hundred fifty dollars ($150) for each incident. Therefore, Covenant shall be required to remit a check made payable to the Continuing Care Provider Fee Fund in the amount of $1,500 within 15 calendar days. If any of the cited deficiencies are not corrected by the noted due dates; additional civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights.

An exit interview was conducted with Ryan Hust via telephone and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Krystall Moore	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2020

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 27-AS-20191209161406

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: COVENANT LIVING OF TURLOCK	FACILITY NUMBER: 500301453
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/05/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/23/2020 Section Cited CCR 87506(c)	1 2 3 4 5 6 7	Resident Records. All information and records obtained from or regarding residents shall be confidential. (1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents...	1 2 3 4 5 6 7	Licensee will provide training to all staff regarding confidentiality of resident records. Proof of training will be provided to CCL via fax by the POC date of 10/23/2020. Civil penalty of $1500 was assessed per letter dated 6/25/2020.
	8 9 10 11 12 13 14	This regulation was not met as evidence by: Based on review of records, the licensee did not ensure that resident records remain confidential. This poses a potential risk to residents in care.	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: Krystall Moore	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2020

LIC9099 (FAS) - (06/04)

Page: 6 of 6