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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 11:51:22 AM

Unsubstantiated


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
09/16/2024 and conducted by Evaluator Seo Jeon
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240916161808
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:Samual 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 preventing resident from sustaining falls.
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 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
Unsubstantiated
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-20240916161808
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 facility staffs encourage the resident to use the call pendent. However, the resident tried to get out of bed by themselves and slid off from bed twice.

Based on observation/ record review/ client interviews, and staff interviews. This allegation is Unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.


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

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
09/16/2024 and conducted by Evaluator Seo Jeon
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240916161808

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:Samual 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 communicating with emergency services regarding resident.
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 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
Unsubstantiated
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-20240916161808
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 facility staffs explained its policy to the emergency service personnels. The facility’s policy will not allow any form of devices to block residents from falling from bed including bed rails. The facility allows bed rails only if the resident is on hospice.

Based on observation/ record review/ client interviews, and staff interviews. This allegation is Unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.


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

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