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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 071405691
Report Date: 01/09/2023
Date Signed: 01/09/2023 01:05:26 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
01/05/2023 and conducted by Evaluator Catherine Lin
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230105090750
FACILITY NAME:ABRAHAM REST HOMEFACILITY NUMBER:
071405691
ADMINISTRATOR:ABRAHAM, SARAFACILITY TYPE:
740
ADDRESS:14 LOMMEL COURTTELEPHONE:
(925) 944-9594
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94597
CAPACITY:8CENSUS: 8DATE:
01/09/2023
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Julio A. Sanchez, AdministratorTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Licensee’s admissions agreement does not meet regulatory standards
Licensee did not refund fees paid in advance upon the resident's death
INVESTIGATION FINDINGS:
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On 1/9/2023 at 9:10 AM, Licensing Program Analyst (LPA) C. Lin arrived unannounced to conduct a 10-day initial complaint investigation visit in regard to the above allegations and delivered investigation findings. LPA met with Administrator and informed the reason for visit.

Allegation: Licensee’s admissions agreement does not meet regulatory standards – Substantiated
The Department has investigated this allegation and per records review and interviews found that the refund policy on Admission Agreement part (9-B) indicated that “No refund of monthly payment will be granted” which was not in compliance with Title 22 California Code of Regulation 87507 Admission Agreements-(5) Refund Conditions.

Continue on LIC9099-C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2023
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-20230105090750
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ABRAHAM REST HOME
FACILITY NUMBER: 071405691
VISIT DATE: 01/09/2023
NARRATIVE
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Allegation: Licensee did not refund fees paid in advance upon the resident's death - Substantiated
The Department has investigated this allegation and per records review and interviews found that facility has not refunded the paid rent for the resident who resided at facility from 11/14/2022 to 12/13/2022 to resident’s family member within 15 days after resident deceased, which was due on 12/28/22.

Based on information obtained, the preponderance of evidence is met, therefore the allegations are substantiated.

Deficiencies are cited from Title 22 California Code of Regulations (see 9099D). Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty.

Deficiencies and plan and proof of correction were discussed with the Administrator, Exit interview conducted. Appeal Rights, LIC9099D, and copy this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20230105090750
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ABRAHAM REST HOME
FACILITY NUMBER: 071405691
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/16/2023
Section Cited
CCR
87507(5)
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87507 Admission Agreements
(5) Refund conditions.

This requirement is not met as evidenced by…
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Administrator agrees to amend the refund policy and resend to the current residents, and submit a copy to CCL by POC due date.
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Based on observation, record review, and interview, the licensee did not comply with the section cited above. LPA observed that facility refund policy "No refund of monthly payment will be granted" was not in compliance which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
01/16/2023
Section Cited
HSC
1569.652(c)
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1569.652 Termination of admission agreement upon death of resident...
(c) A refund of any fees paid in advance...within 15 days after the personal property is removed.

This requirement is not met as evidenced by…
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Administrator agrees to come up with a refund amount and communicate with family member, submit a self-certification to indicate the communication of payment process to CCL by POC due date.
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Based on observation, record review, and interview, the licensee did not comply with the section cited above. LPA observed that facility didn't make the refund within 15 days which was due on 12/28/22, which poses/posed a potential health, safety or personal rights risk to persons 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: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3