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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700581
Report Date: 12/06/2021
Date Signed: 12/06/2021 12:37:20 PM



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
09/28/2021 and conducted by Evaluator Arlene D Garcia
COMPLAINT CONTROL NUMBER: 27-AS-20210928142733
FACILITY NAME:GATE OF BEAUTIFUL II, THEFACILITY NUMBER:
502700581
ADMINISTRATOR:NICOLE ELLFACILITY TYPE:
740
ADDRESS:3300 SHARON AVETELEPHONE:
(209) 526-2425
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:6CENSUS: 5DATE:
12/06/2021
UNANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:Nicole Eli, AdministratorTIME COMPLETED:
12:34 PM
ALLEGATION(S):
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Facility made changes to the resident's Admissions Agreement without the permission of the resident's representative
Facility did not provide a copy of the resident's Admissions Agreement to the resident's representative
INVESTIGATION FINDINGS:
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Licensing Program Analyst, LPA Arlene Garcia visited the facility today to deliver the findings of the complaint investigation for the allegations listed above. LPA spoke with Nicole Eli, Administrator and advised the purpose of LPA's visit.

The initial 10-day visit was conducted on 10/5/2021.

Through the course of the investigation, LPA conducted interviews and reviewed staff and resident records.
It was alleged that facility made changes to the resident's Admissions Agreement without the permission of the resident's representative. LPA reviewed documents and found no changes were made to the Admission Agreement. The facility was requesting for updated physicians report, updated LIC 603. Based on the information, the facility requested and recieved information from the responsible party to evaluate level of care. Facility determined a change in level of care which requires the facility to update the resident forms.

9099 CONT. >>>>>>>>>>>>>>>
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021
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 4
Control Number 27-AS-20210928142733
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: 12/06/2021
NARRATIVE
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It was alleged that the facility did not provide a copy of the resident's Admissions Agreement to the resident's representative.

Interviews reveal the responsible party received a copy of the Admission Agreement. LPA attempted to interview the residents of the responsible party, however, the residents have recently moved out of the facility into a larger care facility. LPA observed 4 of 5 current residents Admissions Agreements. All 4 resident were provided copies of the Admissions Agreements.

LPA observed responsible party of S4 visiting facility with S4's brother-in-law.. Upon entry ED requested for proof of vaccination, completed appropriate health screening and documented on the sign in sheet. Responsible Party stated facility took really good care of S4 and was pleased with the service.

Based on information provided through interviews and documentation, it was unclear that Facility made changes to the resident's Admissions Agreement without the permission of the resident's representative and that facility did not provide a copy of the resident's Admissions Agreement to the resident's representative Therefore, the allegation was deemed UNSUBSTANTIATED, meaning that there was not a preponderance of evidence to prove or disprove that the allegation occurred as reported.
No deficiencies cited. An exit interview was conducted with Administrator Nicole Eli.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021
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, 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
09/28/2021 and conducted by Evaluator Arlene D Garcia
COMPLAINT CONTROL NUMBER: 27-AS-20210928142733

FACILITY NAME:GATE OF BEAUTIFUL II, THEFACILITY NUMBER:
502700581
ADMINISTRATOR:NICOLE ELLFACILITY TYPE:
740
ADDRESS:3300 SHARON AVETELEPHONE:
(209) 526-2425
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:6CENSUS: 5DATE:
12/06/2021
UNANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:Nicole Eli, AdministratorTIME COMPLETED:
12:34 PM
ALLEGATION(S):
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Facility raised resident's rates without proper notice.
INVESTIGATION FINDINGS:
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Licensing Program Analyst, LPA Arlene Garcia visited the facility today to deliver the findings of the complaint investigation for the allegations listed above. LPA spoke with Nicole Eli, Administrator and advised the purpose of LPA's visit.

The initial 10-day visit was conducted on 10/5/2021.

Through the course of the investigation, LPA conducted interviews and reviewed staff and resident records. Interviews confirmed AD made an error on dates of notice and process of notification between level of care and the right to raise rates. AD revised all the forms and sent the RP updated notices as of 10/4/2021. The revised notices were sent certified mail. AD made the revisions for the proper notice between level of care increase and basic rate increase.

It was alleged the facility raised resident's rates without proper notice. Licensing has determined the above allegations are (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiency is cited on 9099-D, per Title 22 Regulations, Division 6. Exit interview conducted and report provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021
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 4
Control Number 27-AS-20210928142733
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: 12/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/15/2021
Section Cited
HSC
1569.655
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§1569.655 Increase in fee rates for elderly residents; 60 days’ written notice stating amount of and reasons for increase; application of section
(a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 60 days' prior written notice to the residents or the residents' representatives setting forth the amount of the increase, the reason for the increase, and a general description of the additional costs, except for an increase in the rate due to a change in the level of care of the resident. This subdivision shall not apply to optional services that are provided by individuals, professionals, or organizations under a separate fee-for-service arrangement with residents.
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Administrator has corrected by reissuing the notice to reflect the 60 day requirement. The notice was resent to responsible party on 10/4/21. Rate increase not effective until 12/4/2021.
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This regulation was not as evidence by the licensee did not ensure to provide proper notice to residents to raise residents rates.
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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 DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4