<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345920289
Report Date: 04/09/2026
Date Signed: 04/09/2026 11:19:39 AM

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
03/04/2026 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20260304105150
FACILITY NAME:ADDIS HOME CARE LLCFACILITY NUMBER:
345920289
ADMINISTRATOR:ORTIZ, MARKMURPHYFACILITY TYPE:
740
ADDRESS:4800 IPSWITCH COURTTELEPHONE:
(952) 564-5468
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 2DATE:
04/09/2026
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Yenne Tezera, LicenseeTIME COMPLETED:
11:35 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not providing resident's authorized representative with a refund
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Licensee, Yenne Tezera, to deliver findings regarding the complaint allegation listed above.

During the investigation, LPA conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows:

Allegation: Staff are not providing resident's authorized representative with a refund

Relevant party reported that resident (R1) resided at the facility from February 1, 2026 to February 7, 2026. R1 passed away on February 7, 2026. Relevant party reported that R1’s authorized representatives did not receive a prorated refund for rent that was paid in advance for the month of February, 2026.

** Report continued on 9099-C **
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026
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 59-AS-20260304105150
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: ADDIS HOME CARE LLC
FACILITY NUMBER: 345920289
VISIT DATE: 04/09/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Interview with Licensee indicated that R1 was admitted to the facility on January 31, 2026 and passed away on February 7, 2026. Licensee indicated that they had not issued a refund to R1’s authorized representatives as the facility did not issue refunds upon the death of a resident receiving hospice services per admission agreement signed by R1’s authorized representative. LPA reviewed Admission Agreement signed by R1’s authorized representative, which states “REFUND POLICY: Refund policy for this facility is ‘Please note that payment are not refundable & a 30 days notice is required for any cancellations/changes.’”

Per Health and Safety Code §1569.652(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.” Per Title 22, Division 6, Chapter 8, Section 87507(h)(4), “The admission agreement shall not contain the following: Any provision that violates the rights of any residents including but not limited to those specified in Section 87468 and in Health and Safety Code section 1569 et seq.”

Relevant party reported that R1’s property was removed from their room to the garage on February 8, 2026 and R1's Power of Attorney removed R1's property from the care home on February 10, 2026. Licensee stated that R1's property was removed from the care home on February 9, 2026.

Based on interviews conducted and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per Health and Safety Code, a deficiency is being cited on the attached 9099-D page.

Exit interview was conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Citations on this Visit Report are Under Appeal!

Control Number 59-AS-20260304105150
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: ADDIS HOME CARE LLC
FACILITY NUMBER: 345920289
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
06/09/2026
Section Cited
HSC
1569.652(c)
1
2
3
4
5
6
7
§1569.652 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 is not met as evidenced by:
1
2
3
4
5
6
7
Facility will refund R1’s authorized representative fees paid from February 10, 2026 to February 28, 2026. Facility will submit proof that refund was issued by POC due date of June 9, 2026.
8
9
10
11
12
13
14
Based on interviews conducted and records reviewed, the facility did not ensure to issue a refund for advance fees paid to R1’s authorized representative upon the removal of R1’s property after they passed away, which poses a potential health, safety, and/or personal rights risk to the residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3