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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426747
Report Date: 10/13/2022
Date Signed: 10/13/2022 01:25:48 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/06/2022 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20221006144016
FACILITY NAME:ANGELIC HANDS ASSISTED LIVINGFACILITY NUMBER:
336426747
ADMINISTRATOR:LUNA, SYNTHIA MARIEFACILITY TYPE:
740
ADDRESS:82397 STRADIVARI ROADTELEPHONE:
(760) 342-0248
CITY:INDIOSTATE: CAZIP CODE:
92203
CAPACITY:6CENSUS: 1DATE:
10/13/2022
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Tinisha Sherley - CaregiverTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility did not provide residents authorized representative with a refund

Facility did not give residents authorized representative a copy of the admissions agreement
INVESTIGATION FINDINGS:
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On today's date, Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of initiating an investigation with the above allegation. LPAs Colvin met with caregiver Tinisha Sherley. Below is a summary of the findings of the investigation:

Regarding allegation "Facility is refusing to provide residents authorized representative with a refund": LPA Colvin conducted interviews with Administrator Synthia Luna and other parties relevant to the complaint. Administrator Synthia Luna confirmed with LPA Colvin that resident (R1) was charged on 9/18/22 for a month residency and care at the facility, and that R1 passed away prior to the conclusion of that month of care charged. Interviews reveal that R1 passed away on 9/27/22, and that R1's family picked up R1's belongings just a few days later, arounf 9/29/22. LPA Colvin inquired as to if R1's family had been provided with a refund of the remaining days of R1's care which was not used (9/30/22 - 10/18/22), and the Administrator stated that they had not. LPA Colvin explained that according to Title 22 Regulations, residents' families may not be charged for any days after the resident's belongings have been removed from the facility.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022
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 18-AS-20221006144016
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ANGELIC HANDS ASSISTED LIVING
FACILITY NUMBER: 336426747
VISIT DATE: 10/13/2022
NARRATIVE
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Therefore, based on interviews conducted, the allegation "Facility did provide residents authorized representative with a refund" is SUBSTANTIATED.

Regarding allegation "Facility did not give residents authorized representative a copy of the admissions agreement": LPA Colvin conducted interviews with Administrator and multiple families of recent residents at the facility. Administrator stated to LPA Colvin that the Admissions Agreement for R1 was completed in R1's family's home, and that R1's family received a copy due to R1's family having a copier at their home and having made copies of other documents to provide the Administrator. Additional interviews provide conflicting information, and persons interviewed for another similar complaint (#18-AS-20220824151755) also claim to have not received a copy of the Admissions Agreement. Administrator does not have any evidence other than their interview that R1's family received a copy of the Admissions Agreement. Therefore, based on more interviews stating that they had not received a copy of the agreement than those stating that they had, the allegation "Facility did not give residents authorized representative a copy of the admissions agreement" is SUBSTANTIATED.

Due to observations made by LPA Colvin, the facility was cited and deficiencies noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy this report, LIC 9099D, and appeal rights were provided to caregiver Tinisha Sherley during the exit interview. Caregiver Tinisha Sherley refused to sign the report, which is noted below. Copies left at the facility for Administrator to review.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20221006144016
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ANGELIC HANDS ASSISTED LIVING
FACILITY NUMBER: 336426747
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/14/2022
Section Cited
HSC
1569.652(a)
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Termination of admission agreement upon death of residen...refund of fees paid...and refunds: (a) A residential care facility for the elderly shall not require advance notice ...upon the death of a resident. No fees shall accrue once all personal property...is removed... This requirement was not met by:
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Licensee agrees to provide R1's family with a refund of monthly rate, prorated from the date after R1's belongings were removed from the facility (9/30/22). Proof of refund shall be provided to LPA Colvin by Plan of Correction date of 10/14/22.
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Based on interviews conducted, the Licensee did not comply with the above regulation with at least one resident. LPA Colvin confirmed that R1's family did not receive a refund for fees prepaid for R1 through 10/18/22. R1 passed away and proprty removed 9/29. This is an immediate personal rights violation of R1.
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Type B
10/27/2022
Section Cited
CCR
87507(e)
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Admission Agreements: (e) The licensee shall provide a copy of the signed and dated current admission agreement,...to the resident or the resident's representative...immediately upon signing the admission agreement... This requirement was not met by:
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Licensee agrees to provide a copy of the Admissions Agreement to R1's family. Adminmistrator may self-certify once complete. Due by Plan of Correction date of 10/27/22.
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 Based on interviews conducted, the Licensee did not comply with the above regulation with at least one resident (R1). Administrator does not have proof that a copy was provided to R1's family, and multiple interviews state that no Admisssions Agreement has been received. This is a potential personal rights violation of R1.
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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: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3