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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803595
Report Date: 12/03/2021
Date Signed: 12/03/2021 02:59:33 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/29/2021 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20211129115859
FACILITY NAME:CARRIAGE HOUSEFACILITY NUMBER:
496803595
ADMINISTRATOR:BLANCAFLOR, JOSEPHINEFACILITY TYPE:
740
ADDRESS:5695 CARRIAGE LANETELEPHONE:
(707) 303-7159
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:6CENSUS: 6DATE:
12/03/2021
UNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Josephine Blancaflor-Licensee/AdministratorTIME COMPLETED:
03:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not provide required due refund in a timely manner
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst(LPA) Dina Alviso arrived unannounced to conduct a complaint investigation regarding the above allegation and met with
Licensee/Administrator Josephine Blancaflor

Complaint alleges that a resident's responsible party was not refunded following resident's passing; Residents personal belongings were moved out 9/22/21. Licensee confirmed to the LPA that she had not reimbursed the due refund within the regulation/HSC required time frame.

The allegation that the facility did not provide required due refund in a timely manner is Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and Health and Safety Code. Appeal rights given to the Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
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 2
Control Number 21-AS-20211129115859
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: CARRIAGE HOUSE
FACILITY NUMBER: 496803595
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/10/2021
Section Cited
HSC
1569.652
1
2
3
4
5
6
7
HSC-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.
1
2
3
4
5
6
7
Licensee to submit facility’s plan of ensuring any due refunds are reimbursed as required and that financial records are accurate; Licensee to also provide proof that resident's responsible party has been reimbursed and received the due refund per law/HSC. POC due no later than 12/10/21.
8
9
10
11
12
13
14
Licensee did not meet this requirement based on financial record reviews, email reviews, and Interviews with Licensee, and other party(s). Per LPA’s review, the refund was requested twice, and Licensee responded to the 2nd request on 11/29/21 that she would have her accountant mail out a check today. Licensee confirmed to the LPA that she had not refunded the responsible party (RP) within 15 days as required for a resident who passed away and whose personal belongings were moved out by 9/22/21. Licensee stated that she has sent out a refund to the responsible party (RP) and she will be notified when the RP receives due refund. This is a personal rights violation.
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: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2