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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003850
Report Date: 01/20/2023
Date Signed: 01/20/2023 11:31:35 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/06/2020 and conducted by Evaluator Patricia Velazquez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20201006154007
FACILITY NAME:WHISPERING OAKS - WAVERLYFACILITY NUMBER:
306003850
ADMINISTRATOR:IMELDA C. CAROFACILITY TYPE:
740
ADDRESS:14782 WAVERLY LANETELEPHONE:
(714) 931-1945
CITY:IRVINESTATE: CAZIP CODE:
92604
CAPACITY:6CENSUS: 5DATE:
01/20/2023
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Imelda Caro - Administrator TIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Licensee failed to provide refund
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Patricia Velazquez and Alvaro Ramirez conducted an unannounced subsequent complaint visit to deliver the findings of the investigation into the above allegation. LPAs Velazquez and Ramirez were allowed entry into the facility and met with Administrator (ADMIN) Imelda Caro and explained the purpose of the visit.

On today's visit LPAs Velazquez and Ramirez conducted an interview with Administrator Imelda Caro. At 10:04 AM LPAs along with ADMIN toured the physical plant. LPAs along with ADMIN observed 5 residents in care and they all appeared well-cared for. Two were in the living room and 3 were in their rooms resting. During the course of the investigation, LPAs Criss Trinidad and Patricia Velazquez conducted interviews with the complainant, witnesses, and staff. LPA Velazquez also reviewed and obtained copies of facility and resident records. The records reviewed included the following for Resident (R) #1: South Coast Medical Center records, Resident Appraisal, Appraisal Needs and Services Plan, Resident's Information Record, Admission
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
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 3
Control Number 22-AS-20201006154007
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: WHISPERING OAKS - WAVERLY
FACILITY NUMBER: 306003850
VISIT DATE: 01/20/2023
NARRATIVE
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Agreement executed on July 2, 2020 and signed by R1’s spouse and Administrator Imelda Caro, Care Partners Home Care Service Agreement executed on July 2, 2020, Physician's Report, Health Essentials itemized list of equipment provided, R1’s Trust bank statements documenting check number ending in 1561 in the amount of $6000 that posted on July 3, 2020 for payment to the facility as well as a debit card purchase in the amount of $468 payable to Care Partners, Legal documents naming one of R1’s children as the Trustee of R1’s Trust Account, email communication between R1’s family documenting return of the certified letters mailed to Administrator Imelda Caro, and R1’s Official Death Certificate documenting R1’s death on July 3, 2020 at 0613 hours with place of death at Whispering Oaks - Waverly. The investigation revealed the following: R1 was discharged from South Coast Global Medical Center on July 2, 2020 to Whispering Oaks – Waverly on hospice. Four of four individuals interviewed corroborated the allegation. ADMIN Caro could not corroborate the allegation. Per one of R1’s family members, Administrator Caro would not accept R1 into the facility until all documents were signed by R1’s POA and a check for $6000 was made payable to the facility. $1000 of that $6000 was for a preadmission fee. R1’s family stated Administrator Caro never provided them with a written statement describing all costs associated with the preadmission fee charges. The family was then asked to pay an additional $468 with a debit card for additional services to be provided by Care Partners. Furthermore when interviewed, Administrator Imelda Caro stated she had not refunded the family what was due to them following the death of R1 on July 3, 2020. R1 was only at the facility for 12 hours with the family paying $6468 up front. Administrator Imelda Caro could not provide LPA Velazquez with written proof of any refund that was made to the family of R1 nor a written statement describing all costs associated with the preadmission fee charges pursuant to statute and regulation.

Based on LPA's observations, interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Licensee failed to provide refund is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D.

An exit interview was conducted with Administrator Imelda Caro and a copy of this report along with the appeal rights, LIC 811, LIC 9098 were provided at the time of this visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20201006154007
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: WHISPERING OAKS - WAVERLY
FACILITY NUMBER: 306003850
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/21/2023
Section Cited
HSC
1569.651(b)
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Preadmission fee or deposit for elderly at residential care facilities; written statement describing costs and stating whether fee is refundable; conditions for refund; refund rate schedules. This requirement was not met as evidenced by: based on interview and record review the licensee failed to provide R1's family with a written statement describing all the costs associated with the $1000 preadmission fee. This poses a potential risk to the health & safety of residents in care.
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Licensee to refund R1's family the $1000 preadmission fee via Cashier's check and mailed overnight to name and address provided. Licensee to provide written proof to LPA by POC due date.
Type B
01/21/2023
Section Cited
HSC
1569.652(c)
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Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds. (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. This requirement was not met as evidenced by: based on interview and record review the licensee failed to provide R1's family with a refund pursuant to statute and regulation. This poses a potential risk to the health and safety of residents in care.
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Licensee to refund R1's family the $5000 via Cashier's check and mailed overnight to name and address provided. Licensee to provide written proof to LPA by POC due date.
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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: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3