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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201493
Report Date: 12/04/2025
Date Signed: 12/04/2025 02:06:03 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/04/2025 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20251204095734
FACILITY NAME:GRAND OAK MANOR SUITE II LLCFACILITY NUMBER:
019201493
ADMINISTRATOR:RAMOS, DIGNAFACILITY TYPE:
740
ADDRESS:999 TORRANO AVETELEPHONE:
(510) 200-9001
CITY:HAYWARDSTATE: CAZIP CODE:
94542
CAPACITY:14CENSUS: 10DATE:
12/04/2025
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Jason Salvador, Care Staff TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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 Staff did not provide a refund to the resident
INVESTIGATION FINDINGS:
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On 12/4/2025 at 8:45 AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct 10 day initial complaint and deliver for the above allegations and met with care staff, Jason Salvador, Administrator (ADM) Dina Ramos was informed via phone regarding the purpose of the visit. ADM was not available during the time of the visit and gave permission to the care staff to sign the report.

On 12/4/2025 at 8:45 AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct 10 day initial complaint and deliver for the above allegations and met with care staff, Jason Salvador, Administrator (ADM) Dina Ramos was informed via phone regarding the purpose of the visit. ADM was not available during the time of the visit and gave permission to the care staff to sign the report.

Allegation: Staff did not provide a refund to the resident- Substantiated

Report continue on LIC 9099c...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025
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 15-AS-20251204095734
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GRAND OAK MANOR SUITE II LLC
FACILITY NUMBER: 019201493
VISIT DATE: 12/04/2025
NARRATIVE
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During the course of the investigation, LPA obtained FR files and interviewed with the Administrator.
Based on record reviews and interviews, Fromer Resident (FR) was admitted at the facility on 10/10/2025 and moved out on 11/13/25. LPA interviewed with ADM and recorded reviews. ADM stated that ADM took a security deposit in the amount of $6500 and recorded reviews showing that ADM took a security deposit amount of $6500 and a preadmission fee amount of $3250 a refund of the amount $5850 to FR.

Security Deposit in the amount of $6500

Preadmission Fee in the amount of 3250 minus 60 percent of FR stayed and minus an excess of $500

Monthly rent in the amount of $6500

Based on LPA’s interviews, which were conducted and record review(s), the preponderance of evidence standard has been met; therefore, the above allegation was found to be SUBSTANTIATED.

An exit interview is conducted a copy of appeal right and report is provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20251204095734
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GRAND OAK MANOR SUITE II LLC
FACILITY NUMBER: 019201493
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/31/2025
Section Cited
HSC
1569.651(h)(3)
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1569.651(h)(3)
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
(h) Unless subdivision (g) applies, preadmission fees in excess of five hundred dollars ($500) shall be refunded according to the following:
(3) If the resident leaves the facility for any reason during the second month of residency, the resident shall be entitled to a refund of at least 60 percent of the preadmission fee

This requirement is not met as evidenced by:
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ADM agree to refund the amount of $1650 to resposible party. ADM agree to send in confirmation once ADM paid the amount to CCLD by POC date.
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 Based on record review and interviews by the Department, Licensee did not comply with the regulation cited above, by not refunding to FR. LPA interviewed with ADM and recorded reviews, showing that ADM took a security deposit amount of $6500 and a preadmission fee amount of $3250, minus 60 percent of the FR stated and minus excess cost of 500 a refund of the amount $1650 to FR.
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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: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3