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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604425
Report Date: 04/26/2023
Date Signed: 04/26/2023 01:00:44 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, 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
02/27/2023 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20230227143122
FACILITY NAME:LA JOLLA CASA FIESTAFACILITY NUMBER:
374604425
ADMINISTRATOR:FERNANDEZ, JENNIFERFACILITY TYPE:
740
ADDRESS:5426 AVENIDA FIESTATELEPHONE:
(858) 775-6935
CITY:LA JOLLASTATE: CAZIP CODE:
92037
CAPACITY:6CENSUS: 4DATE:
04/26/2023
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Tiffany Lynch, House ManagerTIME COMPLETED:
11:01 AM
ALLEGATION(S):
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Licensee did not provide refund
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced visit to initiate a complaint investigation regarding the above-mentioned allegation. LPA identified herself and met with Tiffany Lynch, House Manager deliver to discuss the purpose of the visit and elements of the complaint.

During the visit LPA collected facility records, conducted a tour of the facility and interviews. It was alleged that licensee did not provide refund. Interviews revealed that Resident 1 (R1)s Responsible Party (RP) gave a 30 day notice on December. 26, 2022 and moved the resident out on January. 23, 2023. Interviews revealed that the Responsible Party (RP) returned on January. 24, 2023 to pick up the remainder of R1's belongings. Interviews revealed R1's belongings were moved to the garage and the room was being painted.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
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 08-AS-20230227143122
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: LA JOLLA CASA FIESTA
FACILITY NUMBER: 374604425
VISIT DATE: 04/26/2023
NARRATIVE
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 Interviews reveled that the RP had already made payment through January. 31, 2023. Interviews with RP revealed they believed they still had access to the room and R1's belongings up until January. 31, 2023 but instead, the items that were left behind were moved to the garage.

Documentation provided to the department shows an email to the licensee requesting a refund for the last few days of the month, January. 25, 2023 through - January. 31, 2023.
Interviews revealed that the RP has not received a refund as of the date the investigation was opened on March. 8, 2023.

The allegation is substantiated and is cited on the LIC 9099D page.


An exit interview was conducted with Tiffany Lynch, House Manager. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided and her signature on this report confirms receipt of the Licensee Rights.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20230227143122
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LA JOLLA CASA FIESTA
FACILITY NUMBER: 374604425
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/28/2023
Section Cited
HSC
1569.652(c)
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(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.
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Licensee will provide R1s RP a refund for days 1/25/2023 -1/31/2023 by POC due date of 04/28/2023. Copy of check must be provided to CCL before or on POC due date of 04/28/2023
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This requirement is not met as evidenced by: On 01/23/23 R1 moved out and had paid rent through 01/31/2023. No refund was provided to 1out of 6 residents within the 15 day window. This poses a potential safety risk to residents 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: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3