502700581-6-24-2021-27-AS-SDOB-C4FRN2-20210629130936

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 502700581
Report Date: 06/23/2021
Date Signed: 06/24/2021 09:28:55 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
02/02/2021 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210202161211

FACILITY NAME:	GATE OF BEAUTIFUL II, THE		FACILITY NUMBER:	502700581
ADMINISTRATOR:	ELL, NICOLE		FACILITY TYPE:	740
ADDRESS:	3300 SHARON AVE		TELEPHONE:	(209) 526-2425
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY:	6	CENSUS: 5	DATE:	06/23/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Tisha Ciuffo and Sharon Martin		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility failed to issue a refund.

INVESTIGATION FINDINGS:

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Unannounced complaint visit made out to this facility by LPAs Yang and Hubbard. LPAs were met by the facility caregivers, Tisha Ciuffo and Monica Loya, who were briefly interviewed. This LPA also requested that the facility caregivers go ahead and contact the facility designated Administrator to inform her that CCL was present at this time. The facility designated Administrator, Sharon Martin, arrived later to this facility while this LPA was conducting this visit.
Current census was 5 residents.

87507 Admission Agreements

Refund conditions. 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.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

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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Control Number 27-AS-20210202161211

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: GATE OF BEAUTIFUL II, THE	FACILITY NUMBER: 502700581
	VISIT DATE: 06/23/2021

NARRATIVE

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Based on interviews with facility personnel, this facility was deficient as evidenced by not properly issuing a refund to the responsible party of a resident who had passed away. Based on interviews, the personal belongings and property of this resident had already been removed from this facility by the resident's family and responsible party upon the resident passing away.
This posed a possible threat to the Health, Safety, and Personal Rights of the residents in care.

The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 rules and regulations, Health and Safety Codes.

Appeal rights were printed and given to the facility designated Administrator Sharon Martin.

Exit Interview

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20210202161211

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: GATE OF BEAUTIFUL II, THE	FACILITY NUMBER: 502700581
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/23/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/30/2021 Section Cited CCR 87507(5)(c)	1 2 3 4 5 6 7	Admission Agreements 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, with 15 days after the	1 2 3 4 5 6 7	Facility representative stated that a proper refund will be issued to the responsible party of the resident who had passed away. A copy of the refund check will be processed and submitted into CCL by the due date. A refund was properly given to the responsible party of the resident and a copy of the check
	8 9 10 11 12 13 14	Based on interviews with facility personnel, this facility was deficient as evidenced by not properly issuing a refund to the responsible party of a resident who had passed away. Based on interviews, the personal belongings and property of this resident had been removed from this facility by the resident's family and responsible party.	8 9 10 11 12 13 14	was sent into CCL for review by this LPA. No further plan of correction is required at this time.
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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.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

LIC9099 (FAS) - (06/04)

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