557005530-9-15-2020-27-AS-KHOS-BUZNE7-20201103092329

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 557005530
Report Date: 09/08/2020
Date Signed: 09/15/2020 08:03:23 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
07/22/2020 and conducted by Evaluator Bruce Jacobs

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200722113217

FACILITY NAME:	OAK TERRACE MEMORY CARE		FACILITY NUMBER:	557005530
ADMINISTRATOR:	JACOB PRIMEAU		FACILITY TYPE:	740
ADDRESS:	20420 RAFFERTY CT		TELEPHONE:	(209) 533-4822
CITY:	SOULSBYVILLE	STATE: CA	ZIP CODE:	95372
CAPACITY:	42	CENSUS: 29	DATE:	09/08/2020
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Jacob Primeau, Executive Director		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Resident charged for services not required

INVESTIGATION FINDINGS:

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LPA Bruce Jacobs contacted Executive Director Jacob Primeau by phone to complete this complaint investigation and deliver findings regarding the allegation listed above.

The investigation consisted of interviews of the Executive Director and also other witnesses. LPA requested, obtained and reviewed facility records. The investigation determined that the resident (R-1) was charged for services and those services were included on the service contract. The contact was signed by the responsible party and subsequently paid on a monthly basis and then that fee was then later disputed as unnecessary. The dispute was reviewed by the facility and the facility agreed to resolve the dispute by reimbursing the service fee.

The investigation concluded through interviews and records that there was not sufficient evidence to prove with a preponderance of evidence that the resident (R-1) was charged for services that were not required. For this reason, this allegation is determined to be UNSUBSTANTIATED.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Bruce Jacobs	TELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2020

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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