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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850324
Report Date: 04/02/2024
Date Signed: 04/02/2024 02:54:06 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
03/26/2024 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 29-AS-20240326143505
FACILITY NAME:MALI'S PLACE IFACILITY NUMBER:
565850324
ADMINISTRATOR:JACKSON, SARAFACILITY TYPE:
740
ADDRESS:68 CAMINO CASTENADATELEPHONE:
(818) 274-1809
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:6CENSUS: 2DATE:
04/02/2024
UNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Fidel FranciscoTIME COMPLETED:
02:55 PM
ALLEGATION(S):
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Licensee did not refund fees overcharged to resident’s authorized representative in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint investigation for the allegation listed above. LPA arrived at the facility at 01:25PM and met with facility staff Fidel Francisco. Administrator Sara Jackson was contacted via telephone at 01:28PM and was unavailable during today's visit. Administrator verbally authorized facility staff to sign today's reports. Entrance interview conducted.

During today's visit, LPA interviewed Administrator via telephone at 01:28PM and again at 01:55PM, interviewed staff at 01:50PM, toured the facility at 01:52PM, and attempted to contact Licensee via telephone and text message. No immediate health and safety concerns were identified during today's facility tour. The following was then determined:

Interviews revealed that Resident #1 (R1) had passed away in October 2023. At that time, billing discontinued. Then in January 2024, the facility changed accounting and R1 was charged monthly fees in
REPORT CONTINUED ON LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024
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 3
Control Number 29-AS-20240326143505
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: MALI'S PLACE I
FACILITY NUMBER: 565850324
VISIT DATE: 04/02/2024
NARRATIVE
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January, February, March, and now again in April. Licensee indicated a refund check was issued to R1's estate, however as of today's date has not been cashed. Administrator indicated they had spoken with R1's family member as of 04/01/2024 and the total amount due to R1's estate is $21,000, however the check issued was for $14,000. Fees have been charged since January 2024, but the refund check was not issued until mid-March 2024, and since the resident passed away in October 2023, no fees should have been charged following R1's death. Based on record review and interview, the allegation "Licensee did not refund fees overcharged to resident’s authorized representative in a timely manner" is deemed SUBSTANTIATED at this time.

Pursuant to Title 22 CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D). Administrator was informed telephonically failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

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

DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20240326143505
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: MALI'S PLACE I
FACILITY NUMBER: 565850324
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/16/2024
Section Cited
HSC
1569.652(a)
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§1569.652 (a) A residential care facility for the elderly shall not require...upon the death of a resident. No fees shall accrue once all personal property belonging to the deceased resident is removed from the living unit.
This requirement is not met as evidenced by:
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Administrator agreed to send a copy of the check issued to R1's estate and provide proof of the refund being received and processed by POC due date.
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Based on interview and record review, R1 passed away on 10/19/2023, and fees were charged in January, February, March and likely April 2024 after the resident had passed away, which posed 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: 04/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024
LIC9099 (FAS) - (06/04)
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