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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801851
Report Date: 07/21/2022
Date Signed: 07/22/2022 08:53:29 AM

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
07/13/2022 and conducted by Evaluator Teresa Camara
COMPLAINT CONTROL NUMBER: 29-AS-20220713130343
FACILITY NAME:ROYAL OAKS HOME CAREFACILITY NUMBER:
565801851
ADMINISTRATOR:KAREN ROSALESFACILITY TYPE:
740
ADDRESS:1106 ROYAL AVENUETELEPHONE:
(805) 210-2757
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:6CENSUS: 5DATE:
07/21/2022
UNANNOUNCEDTIME BEGAN:
12:27 PM
MET WITH:Karina AntigTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility did not refund fees paid in advance covering the time after the
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Teresa Camara conducted an initial complaint investigation visit regarding the above noted allegtion. LPA met with co-administrator Karina Antig and explained the reason for the visit.

LPA met with the administrator at 12:50 p.m. The administrator indicated the company had their bookkeeper resign unexpectedly and she lost the information needed in order to provide a refund to the decedent's spouse. The administrator confirmed the decedent passed away on 1/17/22 and the spouse removed the decedent's property on 1/18/22. The spouse had paid fees for 1/16/22 - 2/15/22 in the amount of $4,500. Therefore, the licensee owes the spouse the prorated amount of $4,064.48 for 1/19/22-2/15/22.

The above noted allegtion is deemed Substantiated at this time. Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview conducted. Today's report and appeal rights were discussed and emailed.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
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-20220713130343
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: ROYAL OAKS HOME CARE
FACILITY NUMBER: 565801851
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/28/2022
Section Cited
HSC
1569.652(c)
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§1569.652 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 from the facility shall be issued to the individual, individuals, or entity
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Administrator will ensure a refund is sent to decedent's spouse by 7/28/2022 and send evidence of the payment. In addition, the administrator will review Health & Safety Code 1569.652 and submit a statement of understanding to CCL by 7/28/2022.
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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.
This requirement is not met as evidenced by: Based on information provided by administrator, decedent passed away 1/17/22, decedent's wife removed all property by
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1/18/22 but a refund of the remaining fees has not been given to decedent's spouse.
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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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC9099 (FAS) - (06/04)
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