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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804256
Report Date: 12/05/2024
Date Signed: 12/05/2024 12:29:52 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/08/2024 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20241108134608
FACILITY NAME:SERENE VISTA BOARD AND CAREFACILITY NUMBER:
496804256
ADMINISTRATOR:TRINIDAD, JOELFACILITY TYPE:
740
ADDRESS:184 CALISTOGA RDTELEPHONE:
(707) 755-3946
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:6CENSUS: 3DATE:
12/05/2024
UNANNOUNCEDTIME BEGAN:
12:02 PM
MET WITH:CaregiverTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff did not provide resident's authorized representative with the correct refund
INVESTIGATION FINDINGS:
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At approximately 12:00PM, Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to deliver findings on the above allegation. LPA met with caregiver. Licensee Joel Trinidad was not available to come to the facility. Licensee gave caregiver permission to sign report.

Complaint alleges staff did not provide resident's authorized representative with the correct refund. During investigation, LPA reviewed resident's admission agreement. The rate at the facility was $6300 before facility's change of ownership. After the change of ownership, the resident was moved from a shared room to a single room and the rate increased from $6300 to $7300.

A monthly rate of $7300 breaks down to $235.48 per day. The rate was to cover the time frame of the 15th of the month to the 15th of the next month, in this instance 10/15/24 to 11/15/24.

Continued on 9099C...
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
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-20241108134608
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SERENE VISTA BOARD AND CARE
FACILITY NUMBER: 496804256
VISIT DATE: 12/05/2024
NARRATIVE
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Continued from 9099...

The resident passed away on 10/21/24 and the resident’s personal effects, not including hospice equipment, were removed 10/22/24. So, the resident’s responsible party is responsible to pay a total of eight [8] days for the period covering 10/15/24 to 11/15/24

The daily rate was $235.48 so a total of $1883.84 is the amount due to the licensee to cover the time period of 10/15/24 to 10/22/24. The licensee was paid $7300 to cover the time period of 10/15/24-11/15/24.
• $7300 divided by 31 is $235.48
• $7300 minus $1883.84 is $5416
So, the amount due to the resident's responsible party was $5416.

However, during the resident’s final days of transition, the licensee charged the resident an increased supervision for care needs fee, as the resident now required increased supervision. This increased fee was in the amount of $1000. This fee was agreed to via verbal agreement that occurred via telephone between the licensee and the resident’s responsible party on 10/28/24, as acknowledged in evidence obtained. So the refund due to resident’s responsible party is $4416.

The licensee refunded the resident’s responsible party $4475 on that same day, 10/28/24, the check was mailed to the resident’s responsible party's post office box. On Friday, November 1, 2024 the resident’s responsible party acknowledged, in writing, that they received the check from the licensee in the amount of $4475. Per Health and Safety Code 1569.652(c) a licensee has 15 days after the resident’s personal property is removed to issue a refund of any monies due. In this instance, the licensee refunded the monies due within 6 days.

On 10/25/24 the resident contacted an outside consulting firm to advocate for a refund from the licensee. Per evidence obtained, resident asked licensee to cover half of the fee paid to an outside consulting agency in the amount of $350. However, there is no regulation within California’s Title 22 that requires licensees to pay for advocacy fees.

CCL has investigated the complaint alleging staff did not provide resident's authorized representative with the correct refund. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2