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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700018
Report Date: 05/12/2022
Date Signed: 05/12/2022 03:01:45 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/05/2022 and conducted by Evaluator Anthony Tuck
COMPLAINT CONTROL NUMBER: 27-AS-20220505135231
FACILITY NAME:GROVE HOME CAREFACILITY NUMBER:
342700018
ADMINISTRATOR:BOBOC, LUCIAFACILITY TYPE:
740
ADDRESS:8410 TERRACOTTA CIRCLETELEPHONE:
(916) 225-6405
CITY:SACRAMENTOSTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 4DATE:
05/12/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:TIME COMPLETED:
03:05 PM
ALLEGATION(S):
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Facility refused to give refund balance after resident had passed away
Facility not following Admissions agreement
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Anthony Tuck arrived to the facility location on 05/12/2022 unannounced. LPA was met by Administrator Lucia Boboc and explained the purpose of today's visit to open and investigate a complaint regarding the allegations listed above.

LPA requested and reviewed a copy of the admissions agreement for deceased resident. LPA requested a copy and reviewed an email notice for termination of a admission agreement for the deceased resident from the responsible party. LPA requested and reviewed a copy of the text message between the administrator and a family member of the deceased resident. LPA conducted an interview with the Administrator and 1 staff. LPA conducted a phone interview with 2 family members. Based upon review of the admission agreement and interviews with the administrator, it was learned that, a refund was not issued to the responsible party based on the confirmed date of all personal belongings being removed from the facility. The Administrator admits to not following the admission agreement and issuing a refund to the responsible party due to not keeping track of date of removal of personal belongings from the facility of a resident.
Continued on LIC 9099C...
Substantiated
Estimated Days of Completion: 1
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Anthony Tuck
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
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 27-AS-20220505135231
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: GROVE HOME CARE
FACILITY NUMBER: 342700018
VISIT DATE: 05/12/2022
NARRATIVE
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The preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. The following deficiency was observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. Exit interview was conducted with Lucia Boboc and a copy of this report was provided upon exit..
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Anthony Tuck
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20220505135231
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GROVE HOME CARE
FACILITY NUMBER: 342700018
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/16/2022
Section Cited
CCR
87507(g)(5)(A)
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87507 (g) Admission agreements (5) refund conditions (A) Facility policy concerning refunds, including the conditions under which a refund for advanced monthly fees will be returned in the event of a resident’s death... This requirement was not met as evidenced by:
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Licensee shall ensure that better records are kept based on when a clients personal belongings are removed from the facility.
Licensee shall provide a written statement of understanding to CCLD by POC due date.
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Based upon interviews, telephone calls and
documents received, the licencee did not ensure that refunds were issued based on a residents death and removal of belongings.
This poses a potenetial risk to persons in care.
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Type B
05/12/2022
Section Cited
CCR
87507(f)
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87507 Admission Agreements
(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not met as evidenced by:
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The licensee shall review the regulation cited and review the facility admission agreement and provide and written understanding of the regulation cited to CCLD by POC due date.
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Based upon documents received and interviews conducted, the licensee did not ensure that the admission agreement that was signed by the licensee and responsible party was followed. This poses a potential risk to 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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Anthony Tuck
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3