565801215-8-25-2023-29-AS-DPEA-CV6PAF-20230829110841

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801215
Report Date: 08/25/2023
Date Signed: 08/25/2023 03:22:21 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/18/2023 and conducted by Evaluator Zabel Chochian

COMPLAINT CONTROL NUMBER: 29-AS-20230518095544

FACILITY NAME:	ANGELS II		FACILITY NUMBER:	565801215
ADMINISTRATOR:	JOANN TRUPIANO		FACILITY TYPE:	740
ADDRESS:	2375 MCDONALD COURT		TELEPHONE:	(805) 404-5201
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	6	CENSUS: 4	DATE:	08/25/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Honorata Perla Avestro		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Correct refund was not issued to resident's authorized representative

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver investigation finding. Reason for visit was explained. Staff contacted Administrator. LPA discussed the above allegation investigation finding with Administrator.
Investigation into this allegation consist of records review on 5/19/2023 and 8/22/2023; interview with administrator and staff 5/19/2023; interview with responsible person on 6/23/2023 and 8/22/2023. Based on records reviewed and interviews conducted it was revealed R1 was admitted to facility in late December 2022 with a level 4 monthly services fee of $4500. R1 was assessed to be at level 5 sometime in 2/2023 which increased monthly service fee to $5500. R1's 3/2023 monthly service fee of $5500 was paid in full. R1 passed away at the facility on 3/10/2023. R1's belongings were removed 03/13/2023. A refund of $2250 was issued however this is not the correct refund amount. A refund is due for 18 days (3/14/2023 - 3/31/2023) as follows: $5500/31=$177.42 per day; 18 days x 177.42 =$3,193.56.
Based on information obtained, the allegation is substantiated at this time.
Citation issued (see attached LIC 9099-D). Exit interview conducted. Copy of report and appeal rights issued.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

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 29-AS-20230518095544

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANGELS II	FACILITY NUMBER: 565801215
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/25/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/30/2023 Section Cited HSC 1569.652(a)(c)	1 2 3 4 5 6 7	Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds: (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed......	1 2 3 4 5 6 7	Administrator stated that she communicate with the deceased resident's (R1's) family and provide the correct refund amount totaling $3,193.56. Submit proof of correction by 8/30/2023.
	8 9 10 11 12 13 14	This requirement is not met as evidence by: Based on interviews and records reviewed Administrator did not comply with section cited above. R1's family was not issued the correct refund for unused rent following removal of belongings on 3/13/2023. This posed a potiential personal rights risk to	8 9 10 11 12 13 14	residents in care.
	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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

LIC9099 (FAS) - (06/04)

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