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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204012
Report Date: 06/13/2022
Date Signed: 06/13/2022 06:07:20 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/08/2022 and conducted by Evaluator Martessa Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220608115956
FACILITY NAME:ATKINSON CARE HOMEFACILITY NUMBER:
198204012
ADMINISTRATOR:MUQEET D. DADABHOYFACILITY TYPE:
740
ADDRESS:17035 ATKINSON AVENUETELEPHONE:
(310) 819-8218
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY:6CENSUS: 2DATE:
06/13/2022
UNANNOUNCEDTIME BEGAN:
11:09 AM
MET WITH:Muqueet DadabhoyTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Facility staff failed to issue a refund
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Martessa Brown, conducted an unannounced subsequent complaint visit to deliver findings at Atkinson Care Home regarding the above allegation. LPA met with Leo Sumalponng, Caregiver and was later met by administrator Dadaboy and explained the reason for the visit.

During todays visit LPA toured the facility and obtained the following document R1's Admissions Agreement. LPA conducted interview with the administrator and Staff S1.

The investigation revealed the following:

Allegation: Facility staff failed to issue a refund

LPA conducted interview with the administrator. He stated R1 did not return to the facility per the hospital stated R1 could not return to the facility therefore refund was not due.
LIC9099-C is on the next page

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 11-AS-20220608115956
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ATKINSON CARE HOME
FACILITY NUMBER: 198204012
VISIT DATE: 06/13/2022
NARRATIVE
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He stated the resident items was place in the garage and family was notified around 2 weeks after around March 2022 the hospital to pickup belongings. LPA interviewed s2, stated resident did not return to the facility due breathing complications and hospital kept the resident. S2 stated they had moved out residents belonging 2 weeks after the hospital and son had picked up r1's belongings. LPA reviewed R1 admissions agreement stated under payment provisions, section B the billing and payment policies and procedures are no monthly invoicing, non-refundable processing fee of $500 and non-refundable assessment fee of $500. Based on review the administrator charged R1 to separate fees preadmission fees instead of one.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit Interview Conducted, appeal rights were explained, and a copy of this report was furnished to Leo Caregiver.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20220608115956
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ATKINSON CARE HOME
FACILITY NUMBER: 198204012
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/23/2022
Section Cited
CCR
1569.651(b)(d)
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1569.651 Preadmission fee or deposit for elderly at residential care facilities; written statement describing costs and stating whether fee is refundable; conditions for refund; refund rate schedules (b) If a licensee charges a preadmission fee, the licensee shall provide the applicant or his or her representative with a written admission fee is refundable..(d) Any fee charged by a licensee of a residential care facility ...This requirement was not met as evidence by:
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Licensee will develop a plan on how he is going to comply with regulation and not charging 2 pre-admissions fees and submit a new admissions agreement for the facility to LPA Brow by POC due date.
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Based on observations and interviews conducted, Licensee charged R1 one 2 Pre-Admission fee instead of one and did not describe the associated fee or that it was refundable.
This is a potential health and safety risk to clients in care.
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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.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3