565802441-3-15-2023-29-AS-JAPL-CQ7S32-20230323133024

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802441
Report Date: 03/15/2023
Date Signed: 03/15/2023 01:33:46 PM

Unsubstantiated

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
03/10/2023 and conducted by Evaluator Elsie Campos

COMPLAINT CONTROL NUMBER: 29-AS-20230310145441

FACILITY NAME:	LOVELY COMMUNITY HEALTHCARE		FACILITY NUMBER:	565802441
ADMINISTRATOR:	TOUME, CILVA		FACILITY TYPE:	740
ADDRESS:	52 W NORMAN AVENUE		TELEPHONE:	(805) 852-8770
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 4	DATE:	03/15/2023
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Cilva Toume-Administrator		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Staff refuse to issue resident a refund

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Elsie Campos conducted an unannounced initial 10-day complaint visit for the above allegations. Upon arrival, the LPA met with staff Raymund Escoto and explained the reason for the visit. Administrator, Cilva Toume arrived shortly thereafter.

During today's inspection, the LPA interviewed staff at 11:20 a.m., interviewd the Adminsitrator at 12:02 p.m., conducted a facility tour to ensure there are no health and safety concerns at 11:30 a.m., at 11:45 a.m. the LPA conducted a resident file review and obtained copies of resident records and other pertinent documents relevant to the investigation.

**Continued on LIC 9099-C**

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

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-20230310145441

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: LOVELY COMMUNITY HEALTHCARE	FACILITY NUMBER: 565802441
	VISIT DATE: 03/15/2023

NARRATIVE

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On the allegation: Staff refuse to issue resident a refund

It was alleged that staff refused to issue the resident a refund after they moved out for the remaining (13) thirteen days left in the month that they were no longer living here, 1/19/23-1/31/23. The LPA spoke to the Administrator who confirmed that resident #1 (R1) was under an eviction notice that was in effect September 21^st with an eviction date of October 21^st. The administrator compromised with R1 and the responsible party (RP) that the resident would be able to remain at the facility until they were able to find a new residence. The LPA reviewed R1’s admission agreement page 6 which states under Refund Policy: “in the event that the resident decides to leave the facility with no medical reason, a thirty (30) day written notice to vacate shall be issued to the administrator. Refund shall be issued based on the number of days not used in the month paid”. However, the administrator was not issued a written notice of the intended date to vacate the facility and moved out without written notice on 1/18/23. The facility administrator informed the LPA that the refund dispute was resolved with RP and that the RP for R1 was issued a refund on 3/14/2023 for the remaining days in January that R1 was no longer residing at the facility in the amount of $1500.00. Staff interviews confirmed that the Refund check was picked up and given to R1’s RP on 3/14/23 in the amount of $1500.00. Copies of the check receipt were given to LPA during the visit. Based on information received and documents received, this allegation is deemed to be Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

LIC9099 (FAS) - (06/04)

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