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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801279
Report Date: 05/30/2023
Date Signed: 05/30/2023 02:26:56 PM

Document Has Been Signed on 05/30/2023 02:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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, 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
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:16 PM
MET WITH:Elna Villaflor, AdministratorTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) conducted a case management visit to issue deficiencies observed during a complaint investigation on 5/30/23. LPA met with administrator, Elna Villaflor, to explained the purpose of this case management.

During the complaint investigation for control #28-AS-20230522100241, LPA observed some deficiencies pertaining to the admission agreement. Per observation of Resident #1's (R1) records, the admission agreement was missing the basic rate fees and/or fees for any level of care, although it was signed by the responsible party. In addition, the refund amount was not issued within 15 days after the personal property was removed. R1 passed away on 2/28/23 and Resident #1's (R1) family was issued the refund on 4/26/23.

Based on information gathered, the deficiencies are issued on the LIC809D. An exit interview was held and a copy of this report along with appeal rights was given to the administrator.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR 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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/30/2023 02:26 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 05/30/2023 at 01:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
CCR
87507(g)(3)(A)(1)

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87507 Admission Agreements (g) Admission agreements shall...(3) Payment provisions, including the following: (A) Rate for all basic services...1. A comprehensive description of any items and services provided under a single fee...
This requirement is not met as evidenced by:
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The licensee shall ensure the admission agreement is filled out in its entirety with the basic rates and any additional services provided.

(continue below)
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Based on record review, Resident #1's admission agreement did not list the monthly rates and/or other services rates which posed a potential personal rights risk to residents in care.
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 The licensee shall review all the residents' admission agreements to ensure the rates are accurate and submit a statement indicating the records have been reviewed. The POC is due by 6/13/23.
Type B
06/13/2023
Section Cited
HSC1569.652(c)

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H&S 1569.652 (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 to the individual...within 15 days after the personal property is removed.
This requirement is not met as evidenced by:
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The licensee shall review the admission agreement and health and safety code on refund policies to ensure that refunds are issued proper and timely. The statement acknowledging these regulations have been read is due to LPA by 6/13/23.
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Based on record review, Resident #1 passed away on 2/28/23 and the responsible party was issued a refund on 4/26/23 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.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Cynthia D Chan
LICENSING EVALUATOR 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


LIC809 (FAS) - (06/04)
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