Complaint Unlimited Fee Applies

Cal. Super. - 6th Dist.March 25, 2021

10 ll 12 l3 l4 15 16 l7 18 l9 20 21 22 23 24 25 26 27 28 REHASTE HARVEY WILSON & SALAMOFF, LLP RITA A. REHASTE, ESQ., SBN 15672] J. EDWARD WILSON, ESQ., SBN 246710 ADAM L. SALAMOFF, ESQ., SBN 193686 1221 E. Dyer Rd., Suite 200 Santa Ana, CA 92705 Telephone: (714) 289-7070 Facsimile: (714) 289-707] Attorney for Plaintiff, HAWTHORNE HOLDINGS, LLC, a California limited liability company dba WHITE BLOSSOM CARE CENTER E-FILED 3/25/2021 9:11 AM Clerk of Court Superior Court of CA, County of Santa Clara 21CV381 124 Reviewed By: V. Taylor SUPERIOR COURT 0F THE STATE 0F CALIFORNIA FOR THE COUNTY 0F SANTA CLARA HAWTHORNE HOLDINGS, LLC, a California limited liability company doing business as WHITE BLOSSOM CARE CENTER, ) ) ) ) . . ) Plaintiff, ) ) VS. ) PIERRE YEE-CHOW YING aka PIERRE )) YEE CHOW YING, an individual; ) SONIA SO-HANG YING aka SONIA SO )HANG YING, an individual; and )DOES 1-20, inclusive, ) ) ) ) ) ) ) ) ) Defendants. Plaintiffalleges: GENERAL ALLEGATIONS Case N0. 21 CV381 124 COMPLAINT FOR: (1) BREACH 0F WRITTEN CONTRACT; (2) COMMON COUNTS; AND (3) QUANTUM MERUIT 1. Plaintiff HAWTHORNE HOLDINGS, LLC, is, and at all times herein mentioned was, a limited liability company duly organized and existing under the laws of the State of California, and doing business as WHITE BLOSSOM CARE CENTER in the County of Santa Clara, State of California. Plaintiff is licensed as a skilled nursing facility. Isomlcx 03222021 _ 1 Complaint 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 2. Plaintiff is infonned and believes and thereon alleges that defendants PIERRE YEE-CHOW YING aka PIERRE YEE CHOW YING (hereinafter "Defendant Pierre") and SONIA SO-HANG YING aka SONIA SO HANG YING (hereinafter "Defendant Sonia") are, and at all times mentioned were, individuals residing in the County of Santa Clara, State of California. 3. The true names and capacities of those Defendants sued herein as Does I through 20, inclusive, are unknown to Plaintiff, who therefore sues said Defendants by such fictitious names. Plaintiff will amend this complaint to show the true names and capacities of those Defendants when the same have been ascertained. Whenever reference is made to any named party to this action including, but not limited to, references to "Defendants," "Defendant Pierre," "Defendant Sonia," or other like terms, it shall include said "Does." 4. Plaintiff is infonned and believes and thereon alleges that each of the named Defendants and each of the fictitiously named Defendants is the agent or employee of the remaining Defendants, and/or is the correct name of a Defendant otherwise mistakenly named herein, and/or is responsible as an employer, actor, guarantor, successor, assign or in some other manner, directly, vicariously, or indirectly, for the occurrences and damages hereinafter alleged. 5. On or about October 2019, at San Jose, California, Defendants entered into a written contract (hereinafter "the Contract") with Plaintiff. Defendant Sonia signed the Contract as Defendant Pierre's agent and as the "Resident's Representative." A true and correct copy of the Contract (sans attachments) entitled "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" is attached hereto as Exhibit "A" and by this reference incorporated herein. Pursuant to the tenns of the Contract, Plaintiff agreed to provide to Defendant Pierre, for a fee, skilled nursing facility care and services, as more particularly described in the Contract, and Defendants agreed to pay for said skilled nursing care and services. 6. Defendant Pierre has been a patient at Plaintiffs skilled nursing facility since 27 on or about October 9, 2020, and as of the date this Complaint is filed, Defendant Pierre 28 remains a patient at Plaintiffs skilled nursing facility. Therefore, Defendant will continue /50711/CX 03222021 2 Complaint 10 ll 12 l3 l4 15 l6 17 l9 20 2| 22 23 24 25 26 27 28 to incur charges as hereinafter alleged. 7. Defendant Sonia executed the Contract as the “Resident’s Representative” for Defendant Pierre, and as such, Defendant Sonia agreed to “provide reimbursements from the Resident’s assets to the Facility in compliance with Section V. of the agreement.” 8. Plaintiff is informed and believes and thereon alleges that at all times herein mentioned, Defendant Pierre and Defendant Sonia were, and are, husband and wife, and that the debt owed to Plaintiff herein was incurred during the marriage and is a community debt. Pursuant to Family Code §§ 914(a) and 910, the separate and community property interests of Defendant Sonia are liable for the debt to Plaintiffas Plaintiff provided a necessary of life to Defendant Pierre and the debt is based upon a contract made during the marriage. FIRST CAUSE OF ACTION (Against All Defendants for Breach of Written Contract) 9. Plaintiff refers to and realleges paragraphs 1 through 8, inclusive, as if set forth at length herein. 10. Plaintiff has performed all conditions, covenants and promises required by Plaintiff on Plaintiff’s part to be performed in accordance with the terms and conditions of the Contract. l l. Defendants have breached the Contract by failing to pay all monies owed to Plaintiff in accordance with the terms of the Contract, despite Plaintiff’s demand therefor. As a result of said breach, Plaintiff has been damaged in the sum of $42,340.00 for charges incurred through March 19, 2021. 12. Additionally, as of the date this Complaint is filed, Defendant Pierre remains a patient at Plaintiff‘s skilled nursing facility. As a result, room and board charges will continue to accrue at the current daily rate of $450.00, or such other rate as may be established between the parties, plus ancillary charges according to the terms of the Contract (including transportation charges), of approximately $2,500 each month, from March 19, 2021 , until entry ofjudgment or according to proof at the time of trial. 13. Plaintiffrequests costs and pre-judgment interest on the unpaid balance at the legal rate of ten percent (10%) per annum, according to proof at the time of trial. 1507121CX 03222021 3 Complaint 19 1] 12 13 14 15 16 l7 18 19 20 21 22 23 24 25 26 27 28 SECOND CAUSE OF ACTION (Against All Defendants for Open Book Account) 14. Plaintiff refers to and realleges paragraphs l through 13, inclusive, as if set forth at length herein. 15. Within the past two years, Defendants became indebted to Plaintiffon an open book account for money due in the sum of $42,340.00 for skilled nursing care and treatment provided by Plaintiffto Defendant Pierre through March 19, 2021. 16. Although Plaintiff has made a demand to Defendants for the balance due, neither the whole nor any part of the above sum has been paid, and there is now due, owing and unpaid from Defendants to Plaintiff the sum of $42,340.00, with interest thereon at the legal rate of ten percent (10%) per annum, according to proof at time of trial. 17. Additionally, as of the date this Complaint is filed, Defendant Pierre remains a patient at Plaintiff‘s skilled nursing facility. As a result, room and board charges will continue to accrue at the current daily rate of $450.00, or such other rate as may be established between the parties, plus ancillary charges according to the terms of the Contract (including transportation charges), of approximately $2,500 each month, from March l9, 2021 , until entry ofjudgment or according to proof at the time oftrial. l8. Plaintiff has incurred attorney fees in connection with this matter, which fees Plaintiff is entitled to recover from Defendants pursuant to Civil Code §l717.5. THIRD CAUSE OF ACTION (Against All Defendants for Quantum Mernit- for Reasonable Value of Services) 19. Plaintiff refers to and realleges paragraphs 1 through l8, inclusive, as if set forth at length herein. 20. Within the last two years, Plaintiff provided skilled nursing facility services to Defendant Pierre, who is Defendant Sonia’s husband. Defendants knew these services were being provided and promised to pay Plaintiff the fair and reasonable value of said services. 21. Plaintiffhas performed all conditions, covenants and promises required on its 1507mm 03222021 4 Complaint 10 ll 12 13 l4 15 16 18 l9 20 21 22 23 24 25 26 27 28 part to be performed. 22. The charges for services provided total $42,340.00 through March 19, 202]. 23. Although Plaintiff has made a demand to Defendants for the balance due, Defendants have failed and refused, and continue to fail and refuse, to pay Plaintiff for the reasonable and customary value of Plaintiff’s services. Plaintiffhas therefore been damaged in the sum of $42,340.00, plus interest on the unpaid balance at the legal rate of ten percent (l 0%) per annum, according to proof at the time oftrial. 24. Additionally, as of the date this Complaint is filed, Defendant Pierre remains a patient at Plaintiff’s skilled nursing facility. As a result, room and board charges will continue to accrue at the current daily rate of $450.00, or such other rate as may be established between the parties, plus ancillary charges according to the terms ofthe Contract (including transportation charges), of approximately $2,500 each month, from March l9, 202], until entry ofjudgment or according to proof at the time of trial. WHEREFORE, Plaintiff prays forjudgment against Defendants, and each of them, as follows: UNDER ALL CAUSES OF ACTION 1. For damages in the sum of $42,340.00 for charges incurred through March l9, 2021; 2. For such additional room and board charges that may accrue at the current daily rate of $450.00, or such other rate as may be established between the parties, from March 20, 202] , until entry ofjudgment or according to proof at the time of trial; _3. For ancillary charges of approximately $2,500.00 per month, from March 20, 202 l , until entry ofjudgment or according to proofat the time of trial; 4. For interest on the unpaid balance at the legal rate of ten percent (10%) per annum, according to proof at time of trial; 5. For attorney fees as allowed by Civil Code §l7l7.5; 6. For costs of suit incurred herein; and \\ \\ 150712/Cx_03222021 5 Complaint 10 ll 12 l3 l4 16 l7 l8 20 21 22 23 24 25 26 27 28 7. For such other and further relief as the Court may deemjust and proper. Dated: March 22, 2021 1507121CX 03222021 REHASTE HARVEY WILSON & SALAMOFF, LLP By: QQ/I J. Edward Wilson, Attorneys for Plaintiff, HAWTHORNE HOLDINGS, LLC, a California limited liability company dba WHITE BLOSSOM CARE CENTER 6 Complaint Exhibit ''A'' 03/19/2021 FRI 15:22 FAX .032/042 Stage or California - Haalth and Human Services Agency Callfomla Department of Publlo Health Resld‘ent Name:W Admlsslon Date:191W Resident Number:m Faclllty Name:WWW CALIFORNIA STANDARD ADMISSION AGREEMENT FOR SKILLED NURSING FACILITIES AND INTERMEDIATE CARE FACILITIES Iizmamm Th5 Calilornia Standard Admisslon Agreement is an admission contract that thls Facility is required by state law and regulation to use. lt is a legally binding agreement that defines the rights and obllgatlons of each person (or party) signing the contract. Please read this Agreement carefully before you sign It. If you have any questions. please dlcuss them with Facility staff before you sign the agreement. You are encouraged to have this contract reviewed by your legal representative. or by any other advisor of your choice, before YOU sign it. You may also call the Office of the State Long Term Care Ombudsman at 1-800-231-4024 for more: informatlon about this Facility. The report of the most recent state llcenslng visit to our faculty is posted n; ‘ =' ~ . - z ‘ and a copy of it or of reporis of prlor Inspections may be obtained from the local office of the Catifornla Department of Publlc Health (CDPH) Licensing and Certification Division 190 ngeo ge San ammg, 5mg zgfi, Sgg Jgaa,9AM If oun facility participates in Lhe MedLCal or Medicare programs, we will keep survey certlflcatlon and omplaint lnvestlgatlo reports for the past three years and wIII make these reports avau ble for anyone to revléw upon request. lf you are able to do so, you are required to sign this Agreement In order to be admitted to thls Facillty. If you are not able to sign this Agreement, your representative may slgn It for you. You shall not be required to algn any other document at the time of, or as a condition of. admission to this Facility. : ll. 2:1 Iflcatlono‘ ' DEFINITIONS In order to make tho Agreement more easily understood. references to "we." "our." "us." "the Faculty." or "our Facillty" erg references to: i sso . Attachment A provides you wlth the name of the owner and licensee of thls facility, and the name and contact Information of a single entity responsible for all aspects of patient care and ope'ration at this facility. Refences to "y0u." "your," "Patient," or "Resident" are references to ' ii: ‘t‘ a TH .‘h 'v’ i 1* 03/19/2021 PR: 15:23 Pm: )0“:va- Shh Of Cillfom‘a- Halflh 0nd Human 80M“.”law _ Canbmla Deplmmn! of Publlc HEM person who wm be receiving care In this Facility. For purposes of thls Agreement. “Resident" has the same meaning as "Patbnt. " The parties m this agreement are the Resident. the Facility. and the Resident‘s Representative 'Refarences to the "Resldant’s Representative" are references toz. _ = the person who will slgn on your behalf to admit you to this Facility. andf‘a‘i! Wh‘q 1h amqmad to make .deoislons for you In the event that you are unable to. To the extent permitted by law you may designate a person as your Representative at any tlmé. Note: the person Indicated as your "Resident's Represantatlva" may be a family member. or by law any of the following: a conservator. a namm daeignetedunder {he Resiaent‘t Amia‘nce He'alth Care Directive or Power of Attorney for H5631?! Gum. 'th‘é; Ragl'dpnz‘s naxt- :uf kingamt other person designated by the Resident consistent With flare law, apemdri authorized-by a-mun or. lithe Resident ls a minor. a person aumorlzad by law to represent the minor. Signing this Agreement as a Resident's Représarmfiva does not, tn and of Itself. make the Reslde‘nt’s Ra‘presentatha nable for the Rosldanea‘ debts. However, a Resident's Represantatlva acting as the Resident's financial consewator or otherWIse responsibie for distribution 'o.‘ the Resident's monies. shall pronde Mltfilé‘mamenm from the Resident‘s ‘aeaeth to‘ the Facility In compliance with Section V. of the agmméml IF OUR FACILITY PARTICIPATES IN THE MEDl-OAL OR. MEDICARE PROGRAM. OUR FACILITY DOES NOT REQUIRE THAT YOU HAVE ANYONE GUARANTEE PAYMENT FOR YOUR CARE BY SIGNING OR COSIGNING THE ADMI83ION AGREEMENT A8 A CONDITION OF ADMISSION. The Payfien to thin Agreement are: fies! el_nt:Wilmi- Réslgem‘a Representatmzfiuwggimg- Saab. ‘lmg Rela‘iohahMMQM' ‘ apou 5Q. Facilitymmmmm j‘ mmam u».. . 1 i aw 1h ah 03/19/2021 FRI 15:23 P_Ax woauoaz Stat. of California - Health and Human Services Money California Dopanmom of Pupil: Hoalth m.Sammamm The Resident hereby consents to routine nursing care provided by the Facillty. as well as emergency care that may be requlred. However.. you have the right, to the extent permitted by law. to refuse any treatment and the .rlght .to be Informed of potential medical consequences should you refuse treatment. We wlll keep you Informed about the routlne nursing and emergency care we provide to you. and we wlll answer your questlons about tho care and services we provlde you. If you are. or become, lncapable of making your own medical decisions. we wlll follow the dlreotlon of a person wlth legal authority to make medical treatment decisions on year behalf, such as a guardian. conaewator. next of kln. or a person designated In an Advance Health Care Directive or Power of Attorney for Heal‘h Care. Following admisslon. we encourage you to provide ua with an Advance Health Care Directive apeclfylng your wlehes as to the care and services you want to receive in certaln clrcumetancee. However. you are not required to prepare one. or to provide us a copy of one, a8 a condltlon of adnfilsslon to our Faculty If you already have an Advance Health Care Dlrectlve, It ls important that you provide us wlth a copy so that we may Inform our staff i 1f you do not know how to prepare an Advance Health Care Directive and wish to prapére one, we wlll help you find someone to asslst you in dolng so Residents of thls Faculty keep all their baslc rights and llberfles as a citizen or resided! of the United States when. and after. they are admitted Because these rights are so Important. both federal and State laws and regulations describe them In detall, and state law require$ that a comprehensive Resident Bill of Rights be attached to thls Agreement. Attachment F entitled "Reeldant Bin of Rights." flats your rigms. as set forth in St' ta and Federal law. For your Information, the attachment also provides the locatlon of your ghts tn statute. _ Vlolations of state Saws and regulations ldentlfled above may subject our Faclllty and oun; staff to civil or criminal proceedings. You have the rlght to voice grievances to us without feat! ol’ any reprlsal, and you may submit complaints or any questions or concerns you may have eHout our services or your rights to the )ocal omce of the California Department of Publlc Health Licensing and Cefilflcaflon Dlstflct Office '- ~ 7 . or the State LonQ-Term Care Ombudsan (See page 1 for contact information) You should review the attached "Resldent BIII of Rights" very carefully To acknowledge that you have been Informed of the “Resident BIII of nghts " please .slgn ham. an» .' aw m»- ah 03/19/2021 FRI 15:24 rm: @035/042 State 9t eoflfcmla - Health and Human Servlou Mano); Galen“: Oapanmnnt oi Public Haasth Beginning on 1919912020 (date), we will provide routine nursing and emergency care and other gewicea to you ln exchange for payment. Our Feclllty has bean approved to receive payment from the following government Insurance prdgrams: m x , MedI-Cal 5 Medicare At the time of admlsslo'n, payment for the care we provide to you will be made by: Rosldont (Private Pay) Madl-CalE Medicare Pan A Medicare Pan B._#ww Privata Insurance: . .. u. ‘ fi... v . 7 (Enter Insurance Company and Policy Number) ~Managad Care Organization:#LJ ‘. . . M Other: - .....--'---Q--II: .__ M“; " ' . ”-1":- «W Resident‘s Shara of Coat. Medl-Cal, Medicare, or a private payer may raqulre that the Resident pay a co-payment co-Ineur‘ance. or a dbductlble. all of which the Facllity considers to b9 the Reeldent's share of coat Falluro by thé Resident to pay hls or her share of cos‘ ls grounds for involuntary discharge of the Resident. If you do not know whether your care In our Facllity can be covered by Medl-Cal or Medicare. we will help you get the Information you need. .You should note that. Ii our Faculty does not participate In Medl-Cai or Medicare and you lateriwant these programs to caver the cost of your care, you may be required to leave the Facility. [APP ICABLE ONLY IF DATE l8 ENTERED:] On MA (date) our Facility notified the Calif rnia Department of Health Cara Services-of our intent to withdraw from the Medi-Cal 'Progrbm. If you are admitted afler that date. We cannot accept Medl-Cal relmbursament on your fiehalf. and we will not be required to retaln' you as a Resident If you convert to Medi~Cal ‘relmb. rsement during your stay here. It. on the father hand. you were a Resident here on that date. we are required to accept Medl~Cal reimbursement on your behalf, even if you become ellgible for Medi~Cal reimbursement after that date £1: : i aw ' n ’ 4 m- “ '. 03/19/2021 pa: 15:24 nx [035/042 State of Ogllfomta - Health and Human Services Aganoy Califomll Department d Puhflc Health YOU SHOULD BE AWARE THAT NO FACILITY THAT PARTICIPATES IN THE MEDI-CAL PROGRAM MAY REQUIRE ANY RESIDENT TO REMAIN IN PRIVATE PAY STATUS FOR ANY PERIOD OF TIME BEFORE CONVERTING TO MEDl-CAL COVERAGE. NOR. A3 A CONDITION OF ADMISSION OR CONTINUED STAY IN SUCH A FACILITY, MAY THE FACILITY REQUIRE ORAL 0R WRITTEN ASSURANCE FROM A RESIDENT THAT HE OR SHE IS NOT ELIGIBLE FOR. OR WILL NOT APPLY FOR, MEDICARE 0R MEDIaCAL BENEFITS. our #acllity charges the following basic daily ratesr _.$,5QQ.QQ__,Private 'm Private stalled “ Seml-Prlvate Bed-M SemI-Prlvate Skilled 5 5.99.99 Ward ' $490.09 Ward Skilled The basic daliy rate for private pay and privately insured Residents Includes payment for the services and supplies described In Attachment 8-1. The basic daily wll! be charged for the day of admlssion. but not for any day beyond the day of discharge or death. However. if you are voluntarily discharged from the Facility less than 3 days after _the date of admission we may charge you for a maxlmum of 3 days at the basic daily rate We wm provide you wlth a 30-day written notice before Increasing the basic daily rate. untess the Increase Ia requlred because the State Increases the Medi-Cal rate to a level hlgher than our regular rate. In this case. state law waives the 30-day notlflcatlon. Attachment B~2 lists for prlvate pay and privately insured Residents Optional supplies and saercas not Included in our basic daily rate, and our charges for those supplies and servlces. We wm only charge you for optional supplies and services that you specifically request. unless the supply or service was requlrad in an emergency. We wlil provide you a soyday written notice before any Increase in charges for opuonal supplies and services. If you become eilgible for Medl-Cal at any tlma after your admlssion. the services Ind supplies included in the dally rate may change. and aIso the list of optional sUpplies and services. At the tlme MedI-Cal confirms It wlll pay for your stay in thls Facillty. we wllt revlew and explain any changes In coverage. 03/19/2021 nu 15:25 Fax I037/042 Slat‘a of California - Hnaflh and Human Sowicea Agancy California Department of Public Health x. Jf you are a private pay or privately Insured Residnnt. we require a security deposit of $ Q. We will return the security deposlt to you. with no deduction for administratlon or handllng charges, within 14 d'ays after you close your private account or we recelve payment from MedI-CaIL whlchever ls later. |_f your care in our Facility is covered by MedI-Cal or Medicare, no security deposit ls required. If YOU ARE APPROVED FOR MEDI-CAL COVERAGE AFTER YOU ARE ADMITTED TO QUR FACILITY. YOU MAY BE ENTITLED T0 A REFUND. WE WILL REFUND TO YOU ANY RAYMENTS YOU MADE FOR SERVICES AND SUPPLIES THAT ARE LATER PAID FOR BY MEDl-CAL, L588 ANY DEDUCTIBLE OR 8HARE OF COST. WHEN OUR FACILITY RECEIVES PAYMENT FROM THE MEDI-CAL PROGRAM. WE WILL ISSUE A REFUND TO YOU. If you are entitled to benefits under Medi~0a!, Medicare. or prlvate insurance, and If we are a partlcipatlng Provider, we agree to accept payment from them for our basic daily rate. NEI‘EHER YOU NOR YOUR REPRESENTATIVE SHALL 8E REQUIRED To PAY .PRIVATELY FOR ANY MEDl-CAL COVERED SERVICES FROVIDED 1'0 YOU DURING THE TIME YOUR STAY HAS BEEN APPROVED FOR PAYMENT BY MEDI-CAL. UPON PRESENTATION OF THE MEDI-CAL CARD OR OTHER PROOF OF ELIGIBILITY, THE FACILITY SHALL SUBMIT A MEDl-CAL CLAIM FOR REIMBURSEMENT. However, you are stlll responsible for paylng all deductlbles. copayments. coinsurance, and charges for services and supplies that are not covered by MedI-Cal. Medicare. or your Insurance. Please note that our Facility does not determine ‘he amount of any deductible, copayment. or coinsurance you m‘ay be rqquired to pay: rather, Medi~CaI, Medicare. or your insurance carn‘er determlnes these amounts.. . Attachme‘ms C-1, 6-2, and c-fl describe the services covered by the Medl-Cal daily rate, servloes that are covered by Medi-Cal but are not Included in the daily rats. and services that aye not covered by MedI-Cal but are avallabia It you wish to pay for them. Attachmqnts D-1 and D-Z describe the sewicas covered by Medicare. and services that are not coveréd by Medicare but are available If you wish to pay for them. You Ishould note that MedI-Cal will only pay for covered supplies and services if they are medically neCeasary. If Medl-Cal determines that a supply or service ls not medically necessary. we wm ask whether you stlll want that supply or service and If you are willing to pay for it'yourself. We wlli only charge you for optional supplies and services you specifically request. unless the supp'ly or service was required in an emergency. We wlll provide you a 30-day written notice before any Increase 1n charges for Optional supplies and services. m- ' ' :m- aw ' ' ,n 03/19/2021 FRI 15:25 nx [038/042 Stale ot Callfomia ‘ Health end Human SaNIcas Agency Callfomla Department oi Public Health D. Billlnunmm We will provide to you an itemized statement of charges that you must pay every month. You agree to pay the account menthly on the 1st. Payment Is overdue 1O days after the due date. A late charge at an interest rate of MA‘Vo Is . ll! ' As Indicated In Sectlon c. above, refunds may be due to you as a result of Medi~Cal paying for aérvlc‘es and suppllea you had purchased before your ellglbillty for Medi~Cal was approved or for. any gecurlty deposit you may have made. At the time of your dlacharge, you may also be due dthar refunds. such as unused advance payments you may have made for optional services not covered by the daily rate. We wlll refund any money due to you wlthln 14 days of your leaving the Faolllty. We will not deduct any admlnistration or handling charges from any refund due to you. V|iM We wlll hglparrange for your voluntary discharge or transfer to another facillty. ExcapUn an emergency, we wIII not transfer you to another room withln our Facllity against your v’vlahas; unless we glve prior reasonable written notice to you, determlned on a case by case basis. In accord with appllcable “ate and federal requirements. For example. you have a right to fefuge the transfer if the purpose of the transfer is to move you to or from a Madicare-certifled bed; ‘ Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days In advance. However. we may provide less than 30 days notice If the reason for the transfer or discharge ls to protect your health and safety or the health and safety of other Individuals, If your Improved health allows for shorter notice, or If you have been In our Facility for less than 30 days. Our written notlce will Include the effectlve date the locatton to which you will be transferred or discharged, and the reason the action ls necessary The only reasons that we can transfer you to another faclmy or discharge you agalnst your wlshes are: 1) It Is required to protect your welI-belng. because your needs cannot be met In our Facility; 2) .lt Is appropriate because your health has improved enough that you no longer need . the services of our Faclllty; ! ,3.) Your presence In our Faclllty endangers the health and safety of other Individuals: 'Lii'u- 2i? £22: fir 03/19/2021 Pm 15:26 Fax I039/042 State of Cullfomia - Health and Human Sarvloas Agency Gallmmla Dopanmont of Public Health 9.) You have not pald for your stay ln our Facility or have not arranged to have payment i’nade under Medicare, Medl-Cal. or private insurance; Q) Our Facility ceases to operate; ' Q Materill orfradulent mlsrepreeentation of your finances to us. If we participate In MedI-Cal or Medicare, we will not transfer you from the Facility or discharge you soi_e|y because you change from private pay or Medicare to Medl~Cal payment. In our written notice. we 'wlll advise you that you have the right to appeal the transfer or discharge to. the California Department of Health Care Services and we wiil also provide the name, address. and telephone number of the State Long-Term Care Ombudsman. If you aratransfarred or discharfied against your wishes, we wlll provide transfer and discharge plannlng as required by law. Vll._ . l 99 ._ d-a's lf you must be transferred to an cute hospital for seven days or less, we wlll notify you or your reprpsentative that we are willln to hold your bed. You or your representative have 24 hours after receiveing this notice to let s know whether you want us to hold your bed for you. If MedPCal Is paying for your carge, then Medl-Cal will pay for up to seven days for us to hold the pad for you. lf-you are not ettgibla for MedI-Cal and the daily rate ls not covered by your Insurance, then you are responsible for paying: '~ = M, Private ' ‘ g 590,99 .PrivateSkilIedm_ SemI-Prfvate bed mag... Semi-Private skilled MWard I Mm... Ward Skilled {or each day we hold the bed for you. You should be aware that Medicare does not cover costs related to holdlng a bed for you in these sltuations. if we do not follow the notification prOcedure described above. we are required by law (Title 22 California Code of Regulations Sections 72520(o) and 73504(c)) to offer you the next available approprlate bed in our Facility. ' You shomd also note that, If éur Facility participates In Medi-Cal and you are eilglble for MedLCal'r if you. are away from our Faculty for more than seven days due to hospitallzation or othe'r medical treatment, we will readmit you to the first available bed in a semi-private room if y'ou need the care provided by our Faclllty and wlsh to be readmitted. _ ‘ an: m. 1d- - aw "3/1.,[6043 f'lu. 1.98 ‘0 FAA WUUU/U“Z State of Calliomln - Hum: and Human Senna: Aannay Gamma Oapanmenl oi Public Health vm. - ” ' ‘ Out Feblllty has a theft and loss prevention program as required by state law. Al the lime you are admitted. we will glve you a copy of our policies and procedures regardlng protection of your persona! prdperty, as well as copies of the state laws that require us to have these pollcles and procedures. If our Faclllty participates In Medl-Cal or Medlcare and you glve us your written authorization. we wllLagree to hold personal funds for y0u In a manner consistent wlth all federal and state kaw- and regulations. If we are not certlfled by MedI~Cal or Medicare. we may offer these services but are not required to. You are not required to allow us to hold your personal funds for you as a condltlon of admisslon to our Faculty. At your request, we wlll provide you with our policies. procedures. and authorization forms related to our holding your personal funds for you. Ixfrnmm You agree that we may take photOQraphs of you for Identificatlon and health care purposes. We will not take a photograph of you for any other purpose. unless you glve us your pdor written permission to do so. x_mmmmmmemm You have a right to confldantl‘al treatment of your medics} information. You may authorize us to disclose medical Information about you to a famlly member or other person by completing the "Authorizatlon for Dlsclosure ofiMe‘dloal Informatlon" form In Attachment E. xi. I ndsri'nep You agree to comply wlth reasonable rules. policies and procedures that we establish. When you are admitted. we will give you a copy of those rules. policies. and procedures. including a procedure for you to suggest changes to them. A ccpy of the Facility grievance procedure, for resolution of resident complaints about Facility practices. is available; we will also give you a copy of our grievance procedure for resolution of any complaints you may have about our Facility. You may a150 contact the following agencies about any grlevance or complaint you may have: n x: an 'a. 2:. Ir ’ u 2r 05/19/2021 mu 15:27 FAX [041/042 Shte oi Oallfomia ~ Hunh and Human sands“ Apancy Cumomla Depanmenl of Punflo Health Californla Department of Public HealthM Licensing and Certlflcatlon District Office Phone number: (0R) State' Long-Term Care Ombudsman Program Phone number. ‘ ‘ ' ’ ' ‘ xu.WW This Agreem nt and the Attachments to it consititute the entire Agreement between you and us for,the purp ses of .your .admlasion to our Faclllty. There are no other agreements, understandln s, restrictions. warranties. or "presentations between you and us as a condition of your .adm sion to our Facility; This Agreement supersedes any prlor agreements or understandings regardlng your admission to our Facility. All cabtlons and headings are for convenience purposes only. ~and have no Independent meaning. If any provision of this Agreement becomes Invalid, the remaining provisions shall remain In full force and effect. The Facllity's acceptance of a partial payment on any occasion does not constitute a contlnulng waiver of the‘ payment requirements of the Agreement. or othetwlse llmlt the Faolllty’s rlghts under the Agreement; This Agreement shall be construed accofding to the laws of the State of Oaiifomla. Other th'an as noted for a duly authorlzed Resident‘s Representative. the Resident may not assign or othetwise transfer hi8 or her interests In this Agreement. Upon ”yam request we shall provide you or your legal representative wlth a copy of the signed agreement, all attachments and any other documents you sign at admission and shall provide you with a receipt for any payments you make at admlsslon. w» _ :H‘ m: ’ Jn‘ - n ma- .-. .¢-_.._ - --q-_..- .-. VOIi-OIGV‘L 88‘ &‘Jl£l Flu 8mg of Ca Ilfomla - Haalth and Human Bowlooa Anfinoy California Dammm o! Public Heath By sljnlng below, ma Resident and the Faculty agree to the terms of thls Agreement: ' - . W 1- . - . , ‘ x» . '. x A ' - a fl ; ll. . . ' :. .- . . .'. . , _ .. ; I ’ < , l ‘ . ~ . _._....--'"--...__..__.._. .:‘---. ' ~ --" ' 4.. u: I . . :- 4» u n-n -.- --- i-II-I ---r1-n._ 1h 1' $v : gt Admlsslon ih Iocz/oaz