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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197803655
Report Date: 05/08/2025
Date Signed: 05/08/2025 12:27:42 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
05/01/2025 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250501170249
FACILITY NAME:HOME OF PERPETUAL CAREFACILITY NUMBER:
197803655
ADMINISTRATOR:LEAH ANGELA IGNACIOFACILITY TYPE:
740
ADDRESS:3027 WENWOOD ST.TELEPHONE:
(909) 392-3482
CITY:LA VERNESTATE: CAZIP CODE:
91750
CAPACITY:6CENSUS: 4DATE:
05/08/2025
UNANNOUNCEDTIME BEGAN:
09:01 AM
MET WITH:Administrator Leah IgnacioTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility did not issue a refund to resident's responsible party.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 05/08/2025 to address above allegation. Administrator Leah Ignacio arrived shortly after to assist with tour.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident#1 (R1) prior placement discharge/transfer letter, copy of blank admssion agreement, copy of check for R1’s care dated 3/8/2025, Staff#3 interview (S3), Interview with R1’s responsible party, and physical plant tour.

Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
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 28-AS-20250501170249
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: HOME OF PERPETUAL CARE
FACILITY NUMBER: 197803655
VISIT DATE: 05/08/2025
NARRATIVE
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The investigation revealed the following: regarding the allegation “Facility did not issue a refund to resident’s responsible party.” Review of R1’s facility file and staff interviews revealed R1 was admitted into the facility on 03/04/2025. On 03/16/2025, R1 passed away at the facility. Interviews 03/17/2025, R1’s responsible party picked up R1’s personal belongings. Per Health and Safety code section 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, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed Interview with staff and records reviewed revealed as of 05/08/2025, a refund fees has not been issued to R1’s responsible party. This poses a potential risk to the health, safety, or personal rights of persons in care. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated.

One (1) deficiency was issued during this complaint investigation. Exit interview was conducted with Administrator Ignacio. A copy of this report, 9099-D and appeals rights was provided.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20250501170249
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: HOME OF PERPETUAL CARE
FACILITY NUMBER: 197803655
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/16/2025
Section Cited
HSC
1569.652(c)
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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, entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate,
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Licensee agreed to certfy plan to address when a refund will be issued to R1's responsible party no later than 05/16/2025, via email to LPA Ramirez.
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within 15 days, after the personal property is removed. This requirement was not as evidenced by: Facility did not issue refund within 15 days to R1's responsible party. This poses a potential risk to the health, safety, or personal rights of 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.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3