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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601320
Report Date: 10/03/2025
Date Signed: 10/03/2025 03:17:50 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
10/02/2025 and conducted by Evaluator James Sampair
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20251002214702
FACILITY NAME:BELROSE CARE HOME IIIFACILITY NUMBER:
075601320
ADMINISTRATOR:JUNSAY, ROSAFACILITY TYPE:
740
ADDRESS:226 NORMANDY LANETELEPHONE:
(925) 689-8831
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 4DATE:
10/03/2025
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Licensee / Administrator Rosa JunsayTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not provide resident's responsible party a refund.
INVESTIGATION FINDINGS:
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On 10/03/2025, at 2:15 PM, Licensing Program Analyst (LPA) James Sampair arrived unannounced at the facility to investigate the allegation above. Upon entry into the facility, the LPA identified himself and stated the purpose of the visit to Licensee / Administrator Rosa Junsay.

The complaint alleges that staff did not provide Resident R1's responsible party a refund.
The LPA interviewed Witness W1 (R1's Responsible Person) by phone and the Licensee in person at the facility. W1 stated that the Licensee had not sent the refund of the June 2025 prepayment to her. The Licensee confirmed that no refund of that payment had been sent to W1. This data supports the allegation.

Continued on LIC 9099-C. . . .
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025
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-20251002214702
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BELROSE CARE HOME III
FACILITY NUMBER: 075601320
VISIT DATE: 10/03/2025
NARRATIVE
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. . . .Continued from LIC 9099

The preponderance of the evidence standard has been met, and the allegation is SUBSTANTIATED.

The deficiency is cited under the California Code of Regulations listed on LIC 9099-D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted, Appeal Rights, and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20251002214702
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: BELROSE CARE HOME III
FACILITY NUMBER: 075601320
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/08/2025
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 covering the time after the resident’s personal property has been removed from the facility shall be issued . . . within 15 days after the personal property is removed.
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On or before the due date, the Licensee shall refund the fees paid in advance in full to W1.
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This requirement is not met as evidenced by:

Statement from Licensee that the $6,000 pre-payment for June 2025 had not been refunded to Witness W1.
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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: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3