Complaint·March 10, 2022

From approximately 1:15pm to 2:00pm, LPA Kontilis conducted interviews with Ms. Moore and Ms. Santiago and requested copies of documents pertinent to the investigation. On 12/30/2020, from 11:47am to 2:00pm, LPA Kontilis conducted interviews with the Reporting Party, Administrator, and Business Director. From 02/17/2022 at 9:56am through 02/22/2022 at 2:34pm, LPA Lyndia Sager conducted interviews with the Business Director and the Reporting Party. On 02/17/2022, at 10:06 am, LPA Sager requested a copy of R1’s refund for the period of 10/11/2020 through 10/31/2020. On the allegation: Facility failed to issue a refund – On 10/09/2020, R1 passed away at the facility while on hospice. R1’s Representative had previously paid $6,800.25 for the month of October 2020. Per the Business Director, R1’s Representative removed R1’s personal belongings on 10/10/2020. R1’s Representative requested a refund for the remaining days of October 2020. Per interviews with the Administrator and Business Director, once a request for a refund is sent to the Corporate office, it can take up to 90 days to process. LPA Sager reviewed the refund statement from the Pacifica Senior Housing Accounting Department. The statement indicates the refund check for $4,623.39 was mailed to R1’s Representative on 01/25/2021. LPA Sager confirmed with R1’s Representative that they received the refund check in January 2021. On the allegation: Facility failed to provide a copy of the signed Admission Agreement to Resident or the Resident’s Representative upon Resident’s admission into the facility – On 09/16/2019, R1 was admitted to the facility. LPA Sager reviewed R1’s admission agreement, which was signed by R1’s Representative and dated 09/16/2019. The admission agreement was also electronically signed by former Administrator Katrina Pennington. Per information obtained through interviews, R1’s Representative stated they were promised a copy but never received a copy of R1’s admission agreement. Per the Business Director, there is no documentation available that a copy of R1’s admission agreement was given to R1’s Representative. Based on the information obtained through records review and interviews, the allegations “Facility failed to issue a refund” and “Facility failed to provide a copy of the signed Admission Agreement to Resident or the Resident’s Representative upon Resident’s admission into the facility” are deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.