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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881459
Report Date: 10/14/2024
Date Signed: 10/14/2024 11:43:15 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/15/2024 and conducted by Evaluator Seo Jeon
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240815131412
FACILITY NAME:CARLOTTA, THEFACILITY NUMBER:
331881459
ADMINISTRATOR:BOWIE, MOLLYFACILITY TYPE:
741
ADDRESS:41-505 CARLOTTA DRIVETELEPHONE:
(760) 346-5420
CITY:PALM DESERTSTATE: CAZIP CODE:
92211
CAPACITY:250CENSUS: 184DATE:
10/14/2024
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Samuel M de Guzman III, regional operations specialistTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee is not issuing a refund to resident's responsible party as required.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced subsequent complaint visit to the facility. LPA met with Samuel M de Guzman III, regional operations specialist, and informed them of the purpose of this visit. During this investigation, LPA conducted interviews with staff and obtained supportive documentation for review to assist with determining the findings for the above noted allegations. The following was determined.

Continued on LIC9099-C
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024
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 4
Control Number 18-AS-20240815131412
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CARLOTTA, THE
FACILITY NUMBER: 331881459
VISIT DATE: 10/14/2024
NARRATIVE
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During the LPA’s tour of the facility, LPA reviewed the records and interviewed the staffs. Information revealed that the resident’s admission agreement contains refund policy under section 7.2 and 7.3, and the facility was following the specified refund policy.

Based on information obtained from interview, record reviews and observations, the allegation has been deemed as “Unfounded”. An allegation deemed unfounded means “The allegation is false, could not have happened and/or is without a reasonable basis.” Therefore, the outcome of the allegation is regarded as “Unfounded”.

An exit interview was conducted, and a copy of this report was discussed and given to Samuel M de Guzman III, regional operations spcialist.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/15/2024 and conducted by Evaluator Seo Jeon
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240815131412

FACILITY NAME:CARLOTTA, THEFACILITY NUMBER:
331881459
ADMINISTRATOR:BOWIE, MOLLYFACILITY TYPE:
741
ADDRESS:41-505 CARLOTTA DRIVETELEPHONE:
(760) 346-5420
CITY:PALM DESERTSTATE: CAZIP CODE:
92211
CAPACITY:250CENSUS: DATE:
10/14/2024
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Samuel M de Guzman III, regional operations specialistTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not responding to requests for communication by resident's responsible party in a timely manner.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced subsequent complaint visit to the facility. LPA met with Samuel M de Guzman III, regional operations specialist, and informed them of the purpose of this visit. During this investigation, LPA conducted interviews with staff and obtained supportive documentation for review to assist with determining the findings for the above noted allegations. The following was determined.

Continued on LIC9099-C
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20240815131412
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CARLOTTA, THE
FACILITY NUMBER: 331881459
VISIT DATE: 10/14/2024
NARRATIVE
1
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
27
28
29
30
31
32
During the LPA’s tour of the facility, LPA reviewed the records and interviewed the staffs. Information revealed that the resident’s responsible party was advised in person by the business office director about the facility’s refund policy and procedures at the end of July 2024.

Based on information obtained from interview, record reviews and observations, the allegation has been deemed as “Unfounded”. An allegation deemed unfounded means “The allegation is false, could not have happened and/or is without a reasonable basis.” Therefore, the outcome of the allegation is regarded as “Unfounded”.

An exit interview was conducted, and a copy of this report was discussed and given to Samuel M de Guzman III, regional operations specialist.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4