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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197801279
Report Date: 05/30/2023
Date Signed: 05/30/2023 02:23:24 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/22/2023 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230522100241
FACILITY NAME:LEANING PINE, THEFACILITY NUMBER:
197801279
ADMINISTRATOR:VILLAFLOR, ELNA C.FACILITY TYPE:
740
ADDRESS:1809 LEANING PINE DRIVETELEPHONE:
(909) 396-4675
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY:6CENSUS: 5DATE:
05/30/2023
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Romulo Celebrados, House Manager TIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Facility staff did not issue a proper refund.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation for the allegation listed above. LPA arrived unannounced and met with Staff Romulo Celebrados. The purpose of the visit was explained. Administrator, Elna Villaflor, arrived shortly thereafter to assist with the visit.

LPA obtained a copy of the staff and resident roster, reviewed and obtained copies of Resident #1's (R1) file. Interviews were held with the Administrator and 2 Staff.

The investigation revealed the following:
Allegation - Facility staff did not issue a proper refund. Per the Administrator, Resident #1's (R1) responsible party was issued a refund in the amount of $1,250 for the 5 days that R1 was residing at the facility. LPA obtained a copy of the itemized charges with the amount refunded. Upon review of the statement, LPA observed that the days charged for care and supervision was for 2 weeks.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
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 5
Control Number 28-AS-20230522100241
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LEANING PINE, THE
FACILITY NUMBER: 197801279
VISIT DATE: 05/30/2023
NARRATIVE
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Per the Health and Safety Code section 1569.652, (a) A residential care facility for the elderly shall not require advance notice for terminating an admission agreement upon the death of a resident. No fees shall accrue once all personal property belonging to the deceased resident is removed from the living unit.
R1 was admitted to the facility on 2/24/23 and passed away on 2/28/23. Therefore, it appears that the billing for 2 weeks was incorrect and the refund amount should have been greater than what was refunded.

Based on record review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Health & Safety Code, Chapter 3.2), are being cited on the attached LIC 9099D.

An exit interview was conducted. The Plan of Corrections were reviewed and developed with the Administrator. A copy of this report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20230522100241
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LEANING PINE, THE
FACILITY NUMBER: 197801279
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/13/2023
Section Cited
HSC
1569.652(a)
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ยง1569.652 Termination of admission agreement upon death of resident;... (a) A residential care facility for the elderly shall not require advance notice...upon the death of a resident. No fees shall accrue...
This requirement is not met as evidenced by:
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The licensee shall redetermine the amount billed for R1 prior to decease and ensure the family was issued the correct amount. The POC is due by 6/13/23.
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Based on record review and interview, Resident #1 was billed for 2 weeks for care and supervision provided which posed a potential personal rights risk to residents 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.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/22/2023 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230522100241

FACILITY NAME:LEANING PINE, THEFACILITY NUMBER:
197801279
ADMINISTRATOR:VILLAFLOR, ELNA C.FACILITY TYPE:
740
ADDRESS:1809 LEANING PINE DRIVETELEPHONE:
(909) 396-4675
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY:6CENSUS: 5DATE:
05/30/2023
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Romulo Celebrados, House Manager TIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Facility staff took photo of resident without authorization from responsible party.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation for the allegation listed above. LPA arrived unannounced and met with Staff Romulo Celebrados. The purpose of the visit was explained. Administrator, Elna Villaflor, arrived shortly thereafter to assist with the visit.

LPA obtained a copy of the staff and resident roster, reviewed and obtained copies of Resident #1's (R1) file. Interviews were held with the Administrator and 2 Staff.

The investigation revealed the following:
Allegation - Facility staff took photo of resident without authorization from responsible party. According to the administrator, she took a photo of Resident #1 (R1) and sent it to the family via text to show them of the living arrangement. She stated she wanted to show the family member who lived out of state that R1 is settled in his/her own room after admission to the facility. LPA interviewed 2 other staff and they stated they would only take a photo usually for skin condition, upon request of the doctor or nurse for evaluation.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20230522100241
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LEANING PINE, THE
FACILITY NUMBER: 197801279
VISIT DATE: 05/30/2023
NARRATIVE
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LPA reviewed the admission agreement and the responsible party initialed the consent to be photographed for R1. Based on information gathered, there is insufficient evidence to corroborate this allegation.

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

An exit interview was conducted with the administrator. A copy of this report along with the appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5