374603746-3-4-2022-08-AS-JRAE-CD22YD-20220330174830

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603746
Report Date: 03/04/2022
Date Signed: 03/04/2022 02:37:20 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/26/2021 and conducted by Evaluator Tiffany Holmes

COMPLAINT CONTROL NUMBER: 08-AS-20210326083948

FACILITY NAME:	CHHINA'S SENIOR GUEST HOUSE		FACILITY NUMBER:	374603746
ADMINISTRATOR:	CHHINA, JIWAN S		FACILITY TYPE:	740
ADDRESS:	8632 SPRING VISTA WAY		TELEPHONE:	(619) 337-5201
CITY:	SPRING VALLEY	STATE: CA	ZIP CODE:	91977
CAPACITY:	6	CENSUS: 2	DATE:	03/04/2022
		UNANNOUNCED	TIME BEGAN:	12:17 PM
MET WITH:	Jiwan Chhina, Administrator		TIME COMPLETED:	12:40 PM

ALLEGATION(S):

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Staff failed to provide former resident belongings to family.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced visit to close out a complaint. LPA identified herself, was granted entry, and stated the purpose of the visit to Jiwan Chhina, Administrator. During the investigation, LPA toured the facility, conducted interviews and completed a records review. It was alleged that the staff failed to provide former resident's belongings to a family member. Interviews revealed that when Resident 1(R1) arrived to the facility they came with an older computer and some personal items/clothes. Interviews revealed when R1 passed away the family member attempted to gather R1s items and the staff would not release them to the family. Staff interviews revealed they did not release the items to the family member requesting the items due to them not showing the Power of Attorney (POA) to collect the items. Interviews and LPA observation revealed the family member that is requesting the items was not named on any paperwork as the Responsible Party (RP) or POA.The allegation is unsubstantiated. An exit interview was conducted with Chhina. A copy of this report and Licensee Appeal Rights (9058 01/16) were emailed to Administrator after the conclusion of the visit, LPA Holmes requested an electronic message reply to confirm receipt of these documents.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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