507004929-7-13-2023-27-AS-KHOS-CU5N8U-20230727101456

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 507004929
Report Date: 07/12/2023
Date Signed: 07/13/2023 11:30:10 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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
06/16/2023 and conducted by Evaluator Kesha Lewis

COMPLAINT CONTROL NUMBER: 27-AS-20230616122253

FACILITY NAME:	DUTCHOLLOW SUITES I		FACILITY NUMBER:	507004929
ADMINISTRATOR:	CANDIDO, CECILIA		FACILITY TYPE:	740
ADDRESS:	4112 LAURANT COURT		TELEPHONE:	(209) 521-0566
CITY:	MODESTO	STATE: CA	ZIP CODE:	95356
CAPACITY:	6	CENSUS: 3	DATE:	07/12/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	CANDIDO, CECILIA		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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9

Licensee refused to refund rent paid in advance by resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to deliver findings for the complaint for the above allegations. LPA was greeted by licensee and explained the reason for the visit.

Allegation 1 Licensee refused to refund rent paid in advance by resident. Based on review of the admissions agreement and interviews witth R1 and the ombudsmen the allegation is SUBSTANTIATED. The admisionns agreement is missing required information by regulation making the agreement void. The preponderance of evidence standard for this allegation is met, therefore, this allegation is SUBSTANTIATED.

Exit interview conducted. Copy of report given.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha Lewis	TELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023

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-20230616122253

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: DUTCHOLLOW SUITES I	FACILITY NUMBER: 507004929
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/12/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/15/2023 Section Cited CCR 87507(5)(g)(c)	1 2 3 4 5 6 7	Refund conditions. Facility policy concerning refunds, including the conditions under which a refund for advanced monthly fees will be returned in the event of a resident’s death, pursuant to Health and Safety Code section 1569.652. dmission agreements shall specify the following: (1) Basic services, as defined in Section 87101(b), to be made available. (2) Additional items and services which are available. (3) Payment provisions 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	Provided a refund to R1 with in 3 days. LPA provided the licensee with the phone number where R1 could be reached as discussed with R1. Licensee will also update all admissions agreements with required information for all residents and provide a copy to the department via the LPA by 7/24/2023. updates can be emailed to LPA Lewis at Kesha.Lewis@dss.ca.gov
	8 9 10 11 12 13 14	Based on records review and interviews with R1 and the ombudsmen (ON) LPA reviewed the admissions agreement , the licensee did not comply with the section cited. After a review of resident records LPA found that the admissions agreement only had N/A under refunds and no other information which poses a potential health, safety or personal rights risk to persons 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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha Lewis	TELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023

LIC9099 (FAS) - (06/04)

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