<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200901
Report Date: 07/01/2022
Date Signed: 07/01/2022 02:06:28 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
06/21/2022 and conducted by Evaluator Lizette Francisco
COMPLAINT CONTROL NUMBER: 15-AS-20220621125232
FACILITY NAME:ROSE WATERS HOMEFACILITY NUMBER:
079200901
ADMINISTRATOR:BENDER, CHABAFACILITY TYPE:
740
ADDRESS:1719 MENDOCINO DRIVETELEPHONE:
(925) 270-3871
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 5DATE:
07/01/2022
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Rose Kamau, AdministratorTIME COMPLETED:
02:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not issue a proper refund.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 7/1/2022 at 10:45 AM, Licensing Program Analysts (LPAs) L. Francisco and K. Nguyen arrived unannounced to conduct complaint investigation for the above allegation. Upon arrival, LPAs were greeted by Care Staff Samantha Bender. Administrator, Rose Kamau later arrived at 10:57 AM.

During the complaint investigation, LPAs obtained information, interviewed S1, reviewed records and collected documents. Based on information obtained, it was alleged facility did not issue a proper refund. Record review of Admission Agreement indicates R1 moved into the facility on 3/17/2022 and passed away on 4/9/2022. It was noted that R1's belongings were removed from facility on 4/15/2022.

REPORT CONTINUES ON 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
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 6
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
06/21/2022 and conducted by Evaluator Lizette Francisco
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220621125232

FACILITY NAME:ROSE WATERS HOMEFACILITY NUMBER:
079200901
ADMINISTRATOR:BENDER, CHABAFACILITY TYPE:
740
ADDRESS:1719 MENDOCINO DRIVETELEPHONE:
(925) 270-3871
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 5DATE:
07/01/2022
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Rose Kamau, AdministratorTIME COMPLETED:
02:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not issue a refund
Facility did not provide resident a copy of admission agreement
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 7/1/2022 at 10:45 AM, Licensing Program Analysts (LPAs) L. Francisco and K. Nguyen arrived unannounced to conduct complaint investigation for the above allegations. Upon arrival, LPAs were greeted by Care Staff Samantha Bender. Administrator , Rose Kamau later arrived at 10:57 AM.

During the complaint investigation, LPAs obtained information, interviewed S1, reviewed records and collected documents. Based on information obtained, it was alleged facility did not issue a refund. However, a signed Admission Agreement states a one month notice of service termination in writing is required. R2 was admitted to the facility on 4/1/2022 and moved out on 4/11/2022. Interview with S1 revealed a 30-day notice was not issued to the facility in accordance to the admission agreement.

REPORT CONTINUES ON 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20220621125232
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: ROSE WATERS HOME
FACILITY NUMBER: 079200901
VISIT DATE: 07/01/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
It was alleged facility did not provide resident a copy of Admission Agreement. However, based on the signed admission agreement, it was indicated a copy was given to the resident or resident's responsible party. S1 stated responsible party was provided another copy of Admission Agreement on 5/4/2022, LPAs were unable to determine if resident was provided a copy upon admission.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 15-AS-20220621125232
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: ROSE WATERS HOME
FACILITY NUMBER: 079200901
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
07/06/2022
Section Cited
CCR
87507(f)
1
2
3
4
5
6
7
ADMISSION AGREEMENTS
(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator will issue a refund to resident and submit a copy of payment to CCL by POC date.
8
9
10
11
12
13
14
Based on record review, Licensee did not comply with the regulation cited above. LPAs observed a total $2626 for R2's fees and property damage were deducted from R1's refund which poses a potential personal rights to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Lizette Francisco
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 15-AS-20220621125232
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: ROSE WATERS HOME
FACILITY NUMBER: 079200901
VISIT DATE: 07/01/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
An email communication between facility and resident's responsible party indicates a total of $4,862 is owed to R1. However, R1's husband (R2)'s balance of $2,126 and a $500 property damage were deducted from the total amount. Facility was not aware that the funds should not have been commingled, therefore a refund of $2,236 was issued to R1.

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

Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6