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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 372004506
Report Date: 05/23/2022
Date Signed: 05/23/2022 11:54:51 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/17/2021 and conducted by Evaluator Rebecca A Ruiz
COMPLAINT CONTROL NUMBER: 08-AS-20211217110929
FACILITY NAME:CARPEL BOARD & CARE FACILITY #2FACILITY NUMBER:
372004506
ADMINISTRATOR:CARMONA, LEONOR P.FACILITY TYPE:
740
ADDRESS:2091 HANFORD DRIVETELEPHONE:
(858) 569-1691
CITY:SAN DIEGOSTATE: CAZIP CODE:
92111
CAPACITY:6CENSUS: 6DATE:
05/23/2022
UNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Leonor CarmonaTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Licensee did not follow Infection Control practices
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced visit to deliver investigation findings regarding the above mentioned allegation. LPA identified herself, was allowed entry by, and explained the purpose of the visit to Licensee Leonor Carmona.

The Department’s investigation consisted of interviews with staff and outside sources and a tour of the facility. It was alleged that facility staff did not follow COVID-19 Infection Control practices. Outside interviews revealed that facility staff did not wear face coverings or masks while in the facility. During the initial complaint visit on 12/23/2021, LPA Ruiz observed Licensee Leonor Carmona, who resides at the facility, was not wearing a mask or face covering while in the kitchen. LPA Ruiz also observed the Licensee wearing a surgical mask that did not cover her mouth and nose and was pulled down under her chin during the visit.

Continued on LIC9099-C page.
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022
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 3
Control Number 08-AS-20211217110929
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: CARPEL BOARD & CARE FACILITY #2
FACILITY NUMBER: 372004506
VISIT DATE: 05/23/2022
NARRATIVE
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During an interview with the Licensee, she admitted that she does not always wear a mask or a face covering while at the facility and stated it was because she does not provide direct care to residents. The Licensee also acknowledged that she needed to wear a mask or face covering at all times while outside her living quarters.

Based on the evidence obtained during the investigation, the Department has found that facility staff did not follow COVID-19 Infection Control practices. Therefore, the allegation is deemed substantiated, which means that the preponderance of the evidence standard has been met and the allegation is valid. The following deficiency was cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page.

An exit interview was conducted with Licensee Leonor Carmona, to whom a copy of this report and the Licensee Rights (LIC9058 01/16) were provided via hard copy.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 08-AS-20211217110929
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CARPEL BOARD & CARE FACILITY #2
FACILITY NUMBER: 372004506
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/06/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilties (a)(2) To be accorded safe, healthful and comfortable accommodations, furnishing and equipment. This requirement has not been met as evidenced by:
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Licensee will conduct an in-service training on masking guidance and will provide sign in sheet to LPA by POC date.
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Based on interviews and LPA observations, the Licensee did not wear a mask or face covering while at the facility. This poses a potential health risk to 6 of 6 residents.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3