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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 365530072
Report Date: 11/07/2023
Date Signed: 11/07/2023 11:05:20 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
11/01/2023 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20231101131317
FACILITY NAME:VILLA DESCANSO DE AMORFACILITY NUMBER:
365530072
ADMINISTRATOR:THOMPSON, GABRIELAFACILITY TYPE:
740
ADDRESS:15453 ELM LANETELEPHONE:
(909) 393-6201
CITY:CHINO HILLSSTATE: CAZIP CODE:
91709
CAPACITY:6CENSUS: 6DATE:
11/07/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Joaquin ThompsonTIME COMPLETED:
11:10 AM
ALLEGATION(S):
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Facility did not issue a refund to a resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Facility Administrator Joaquin Thompson and explained the purpose of the visit. The investigation consisted of interview and review of records.

First allegation, Facility did not issue a refund to a resident in care. During interview with administrator regarding resident’s refund Administrator stated that the refund pertaining to Resident #1 (R#1) was still pending and has not been issued because of financial reasons. On 11/7/2023 family indicated that Resident #1 was admitted to the facility on 6/30/2023 and Resident #1 vacated the facility on 7/11/2023. Family has stated that they have yet to receive any refund which was indicated by the facility. Based on the evidence gathered during the investigation, the above allegations are Substantiated.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023
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 56-AS-20231101131317
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VILLA DESCANSO DE AMOR
FACILITY NUMBER: 365530072
VISIT DATE: 11/07/2023
NARRATIVE
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Substantiated A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Title 22 regulations, Admission Agreements 87507 a from division 6, chapter, article 6, is being cited on the attached LIC 9099 D.

An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided, along with a copy of the appeal rights. to Facility Administrator Joaquin Thompson at the end of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 56-AS-20231101131317
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: VILLA DESCANSO DE AMOR
FACILITY NUMBER: 365530072
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/01/2023
Section Cited
CCR
87507a
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87507 a. A refund of at least 80 percent of the preadmission fee in excess of $500 shall be provided if the applicant does not enter the facility after a preadmission appraisal is conducted, or the resident leaves the facility for any reason during the first month of residency.

This requirement is not met as evidence by:
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Administrator has agreed to read over the entire Admissions Agreement regulation and provide a signed and written acknowledgement of understanding regarding refund procedures. Administrator will email document to assigned LPA by 12/1/2023
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Based on obervation, interviews and record review, the licensee did not ensure admission agreement "Refund" was followed, which poses an immediate Health, Safety, or Personal Rights 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: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3