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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701344
Report Date: 03/05/2025
Date Signed: 04/03/2025 09:58:49 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
02/04/2025 and conducted by Evaluator Kesha Lewis
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250204143321
FACILITY NAME:DANICA'S HOMEFACILITY NUMBER:
392701344
ADMINISTRATOR:FLORES, OLIVERFACILITY TYPE:
740
ADDRESS:1746 TANAGER AVETELEPHONE:
(510) 584-1787
CITY:MANTECASTATE: CAZIP CODE:
95337
CAPACITY:6CENSUS: 2DATE:
03/05/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:OLIVER P FLORESTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Licensee did not issue resident’s authorized representative a timely refund.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced todeliver findings for the complaint investigation. LPA Lewis met with facility administrator FLORES, OLIVER and explained the purpose of the visit.

Based on records review and interviews with the reporting party and the adminstrator the avove allegation is SUBSTAIATED. During the review of the admissions agreement it was found that an addmendment was added stating that if a resident was on hospice there was not refund to be given. A refund of 3200.08 is due to be refunded within 48 hours. There is a preponderance of evidence to conclude that the allegations noted above are SUBSTANTIATED.

Citations are issued as indicated on LIC 9099D. An exit interview was conducted Appeal rights provided
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025
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 27-AS-20250204143321
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: DANICA'S HOME
FACILITY NUMBER: 392701344
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/03/2025
Section Cited
CCR
87507(8)(a)
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Admission Agreements
General facility policies...All facility policies...shall not violate any applicable rights, laws or regulations.
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Licensee shall send a check to the responsible party for R1 in the amount requested by POC due date. Proof of payment shall be submitted to Community Care Licensing by POC date via fax.
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This requirement is not met as evidenced by: Based on confirmation that the Licensee has not refunded the prorated amout for the pre admission fee and the rent payment for november into decamber in the amount of $3200.08. This violation poses a potential health, and safety risk to residents in care.
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due to facility
99.96- pree admission fee
699.96- rent

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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: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
02/04/2025 and conducted by Evaluator Kesha Lewis
COMPLAINT CONTROL NUMBER: 27-AS-20250204143321

FACILITY NAME:DANICA'S HOMEFACILITY NUMBER:
392701344
ADMINISTRATOR:FLORES, OLIVERFACILITY TYPE:
740
ADDRESS:1746 TANAGER AVETELEPHONE:
(510) 584-1787
CITY:MANTECASTATE: CAZIP CODE:
95337
CAPACITY:6CENSUS: 2DATE:
03/05/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:OLIVER P FLORESTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Licensee did not give responsible party a copy of the admissions agreement in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced todeliver findings for the complaint investigation. LPA Lewis met with facility administrator FLORES, OLIVER and explained the purpose of the visit.

Based on records review and interviews with the reporting party and the adminstrator the avove allegation is UNSUBSTAIATED. During the review of the admissions agreement it was found that is was signed and dated and based oon interviews with the adminstrator and rerorting party it can not be detirmened if the admissions agreement was recieved late or not. There is not a preponderance of evidence to conclude that the above allegation is ture therefor this complaint is UNSUBSTANTIATED.

Exit interview and copy of report given.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3