complaint·September 18, 2025

Continued LIC9099-C page #2 Functional Capability Assessment (Dated 11/06/2024), Preplacement Appraisal Information (Dated 11/06/2024), Consent Form (Dated 11/06/2024), Personal Rights (Dated 11/06/2024), Safeguards for Cash Resources (Dated 11/06/2024), Safeguards for Property/Valuables (Dated 11/06/2024), Death Report (Dated 12/17/2024). The Department conducted interviews with the Staff Member #1 (S1) and Witnesses #1 and #2 (W1-W2). Investigation Reveals the following: Allegation: Staff did not provide a refund upon the resident’s death. It was alleged that Resident 1 (R1)'s room and board were paid for the entire month of December 2024, and staff did not issue a refund upon the resident’s death. At 2:00 p.m., Staff Member #1 (S1) was interviewed and reported that R1 moved into the facility on November 06, 2024, and passed away on December 12, 2024. On December 17, 2025, S1 submitted a copy of the death report to Community Care Licensing regarding R1's passing. R1's Admission Agreement on Refund Conditions/Resident Death, dated November 06, 2024, was reviewed. It states that the facility will refund any fees paid in advance covering the time after the resident's personal property has been removed from the facility within 15 days. One out of one staff member agreed that R1 was owed $3,065.00, which has not been refunded after R1's death and the removal of their belongings. S1 confirmed that, as of today, no payment has been made. On 07/18/2025, the Department interviewed Witnesses #1 and #2 (W1-W2), who stated that Resident #1 (R1) lived at the facility and passed away on 12/12/2024. W1 and W2 reported that they paid for the entire month of December 2024 and have both spoken to Staff Member 1 (S1) regarding the refund they are owed. W1 and W2 stated that S1 requested that payment arrangements could be made in monthly installments; however, no payments have been made. See continued LIC9099-C page 3 Continued LIC9099-C page 3 Based on LPA’s observations, interviews that were conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D. Appeal rights were discussed, and copies of the Complaint Investigation Report LIC 9099 and LIC9099-C were provided to Licensee Delores Davis. Exit interview conducted.