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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198202539
Report Date: 08/30/2021
Date Signed: 08/30/2021 01:39:21 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/30/2021 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20210430081729
FACILITY NAME:EMERALD ISLE ASSISTED LIVING IIIFACILITY NUMBER:
198202539
ADMINISTRATOR:LAURA MARTZFACILITY TYPE:
740
ADDRESS:27781 HAWTHORNE BLVDTELEPHONE:
(310) 544-3308
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:6CENSUS: 4DATE:
08/30/2021
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:ADMINISTRATOR LAURA MARTZTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility staff increased the residents rent without proper notice.

INVESTIGATION FINDINGS:
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On 8/30/2021 around 10:00am Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Today’s complaint investigation was conducted face to face with Administrator Laura Martz.

The Investigation consisted of the following: On 4/30/2021 LPA Calderon interviewed witness W1 for complaint. On 04/30/2021 reviewed complaint paperwork. On 04/30/2021 LPA Calderon reviewed admission agreement and invoices supplied by witness 1. On 05/10/2021 LPA Calderon reviewed email paperwork from witness 1 for complaint. On 08/30/2021 LPA Calderon interviewed Administrator Laura Martz S1.

The investigation revealed the following:

Allegation: Facility staff increased the residents rent without proper notice.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
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 11-AS-20210430081729
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: EMERALD ISLE ASSISTED LIVING III
FACILITY NUMBER: 198202539
VISIT DATE: 08/30/2021
NARRATIVE
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It is alleged Facility staff increased the residents rent without proper notice. On 04/30/2021 LPA Calderon interviewed witness 1 who confirmed that facility had increased service fees for resident 1 diet plan by $500.00 per month starting 1/15/2021. On 04/30/2021 LPA Calderon reviewed emails from Administrator Laura Martz stating she would refund residents account but has not done so at this time. On 04/30/2021 LPA Calderon reviewed admission agreement and confirmed per agreement that diet plan is part of the service charge and that the facility violated the agreement and could not charge the additional amount of $500.00 per month. On 05/10/2021 LPA Calderon reviewed invoices, emails that confirm the facility agreed that additional charges were not in line.

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

Deficiencies cited under California Code of Regulations, Title 22, Division (6) and chapter (8) are being cited on the attached LIC 9099D.

A telephonic exit interview was conducted, appeal rights discussed with Administrator Laura Martz, and a hard copy was provided by hand for facility records
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 11-AS-20210430081729
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: EMERALD ISLE ASSISTED LIVING III
FACILITY NUMBER: 198202539
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/10/2021
Section Cited
CCR
87507(G)(3)(B)(2)
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87507 Admission Agreements: (3) Payment provisions,including the following:(B) Rate for additional items and services, including: 2 A separate charge for an item or service may be assessed only if that charge is included in and authorized by the admission agreement. This requirement is not met as evidenced by:
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Administrator will meet with POA and determine the total amount of refund owned since 1/15/2021 and will email LPA Calderon with plan of correction no later than 09/10/2021
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Based on records review the admission agreement does not support the facility charging an additional $500.00 for a prescribed meal plan which poses an personal rights risk to person 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.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3