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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700761
Report Date: 07/23/2024
Date Signed: 07/23/2024 03:43:44 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/18/2024 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 59-AS-20240718091516
FACILITY NAME:SPLENDOR OAKS SENIOR LIVING 1FACILITY NUMBER:
342700761
ADMINISTRATOR:LEE, KEVINFACILITY TYPE:
740
ADDRESS:3609 VOLEYN STTELEPHONE:
(916) 993-9921
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 5DATE:
07/23/2024
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:CaregiversTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff did not issue a refund
INVESTIGATION FINDINGS:
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On 7/23/24, Licensing Program Analyst (LPA) Kevin Mknelly spoke with Maria Cucicea by phone to open the complaint and to deliver complaint findings for the above allegation.

LPA reviewed resident records and conducted and interview . LPA finds that the allegations cited above are substantiated. R1 movied into the facility on 5/7/23 and the contract was terminated on 5/23/24. LPA and Maria discussed fees charged and fees to be refunded. It was found that, through human error, the refund, paid today, exceeded the 15 days from the time of move out.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.
Report reviewed with caregiver. Copy of this report and appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
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 2
Control Number 59-AS-20240718091516
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SPLENDOR OAKS SENIOR LIVING 1
FACILITY NUMBER: 342700761
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/30/2024
Section Cited
HSC
1569.652(c)
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Admission agreement. (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
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Assistant administrator informed LPA that they are resolving the issue today.
Licensee agrees that LPA will rceive confirmation for R1's POA that fees have been reimbursed by the POC date of 7/30/24.
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 fees, to the resident’s estate, within 15 days after the personal property is removed.
This requirement was not met based on one of one residents who's fees were not refunded within 15 days.
This posed a potential risk.
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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: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC9099 (FAS) - (06/04)
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