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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802441
Report Date: 02/18/2025
Date Signed: 02/18/2025 01:04:43 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/11/2025 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 29-AS-20250211121654
FACILITY NAME:LOVELY COMMUNITY HEALTHCAREFACILITY NUMBER:
565802441
ADMINISTRATOR:TOUME, CILVAFACILITY TYPE:
740
ADDRESS:52 W NORMAN AVENUETELEPHONE:
(805) 852-8770
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 6DATE:
02/18/2025
UNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Cilva ToumeTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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Licensee did not provide the correct refund to resident’s representative
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint investigation for the allegation listed above. Upon arrival, LPA met with facility staff who called the Licensee to inform them of the LPA’s visit. LPA spoke with Licensee Cilva Toume at 09:55AM. Licensee arrived at 10:32AM. Entrance interview conducted.

The complaint alleges that Resident #1 (R1) had moved into the facility on 12/30/2024 and passed away at the facility on hospice care on 01/05/2025 and R1’s responsible party did not receive a full refund to date. LPA obtained copies of R1’s admission agreement and R1’s documents filled out upon admission. Interview with Licensee revealed that they had discussed refunds and had verbally agreed that no refund would be issued for R1’s fees paid for January 2025 due to additional care R1 required while R1 was present at the facility. LPA reviewed R1’s admission agreement signed by R1’s responsible party and Licensee. R1’s

Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025
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 29-AS-20250211121654
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: LOVELY COMMUNITY HEALTHCARE
FACILITY NUMBER: 565802441
VISIT DATE: 02/18/2025
NARRATIVE
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admission agreement does not contain language related to refunds issued when a resident is on hospice or fees incurred due to additional care. Admission Agreement does contain language related to $500 non-refundable pre-admission fee, however the line was left blank inadvertently according to Licensee. Title 22 regulation does not contain specific language related to refunds when a resident is on hospice care. Basic services charge for December was $333.33 and Admission Agreement indicates monthly fee is $5000.00 per month. Interview revealed that R1’s personal belongings were removed on 01/06/2025. Licensee confirmed that a check for $333.33 was mailed to R1’s responsible party, however no additional refunds were issued. Based on interview and record review, the preponderance of evidence standard has been met, therefore the allegation is deemed SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 of the CA Code of Regulations and/or CA Health and Safety code, the following deficiencies were cited (refer to LIC 9099-D.)

Exit interview was conducted. A copy of today’s report and appeal rights were provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20250211121654
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LOVELY COMMUNITY HEALTHCARE
FACILITY NUMBER: 565802441
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/04/2025
Section Cited
HSC
1569.652(c)
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§1569.652 (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...resident’s estate, within 15 days after the personal property is removed.
This requirement is not met as evidenced by:
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Licensee agreed to communicate with R1's family related to the refund and whether a pre-admission fee will be included. Remaining refund (excluding amount already refunded) will either be $3666.67 or $3166.67. Proof of refund issued will be provided to CCL by POC due date.
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Based on interview and record review, the Licensee did not comply with the above cited section, as R1 passed away and all belongings were removed as of 01/06/2025 and correct refund has yet to be issued, which poses a potential personal rights 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: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025
LIC9099 (FAS) - (06/04)
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