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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405801701
Report Date: 04/13/2022
Date Signed: 04/13/2022 04:54:40 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/22/2021 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20211022094417
FACILITY NAME:C.A.L.L.-CARMELITA HOUSEFACILITY NUMBER:
405801701
ADMINISTRATOR:COURTNEY MOOREFACILITY TYPE:
740
ADDRESS:2660 FERROCARRILTELEPHONE:
(805) 466-8502
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:6CENSUS: 6DATE:
04/13/2022
UNANNOUNCEDTIME BEGAN:
03:52 PM
MET WITH:Regina Ceasar, Administrator for CALL Day ProgramTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff yell at residents.
INVESTIGATION FINDINGS:
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On 4/13/2022 at 3:52 pm, Licensing Program Analyst (LPA) Chavez initiated an unannounced complaint visit to discuss the final findings for the allegation listed above. LPA met with Regina Ceasar, Administrator for C.A.L.L. /Day Program and explained the reason for the visit.

Regarding the allegation, “Staff yell at residents,” the complainant was concerned that Staff #1 (S1) yelled at Resident #1 (R1) on 10/21/21. Complainant states that S1 was assisting R1 with applying deodorant, and R1 would not lift R1’s arm. Further, that S1 said to R1 “Why are you fighting with me? Stop fighting with me?” To investigate the allegation, LPA interviewed staff and reviewed records.


Continued on 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022
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 8
Control Number 29-AS-20211022094417
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: C.A.L.L.-CARMELITA HOUSE
FACILITY NUMBER: 405801701
VISIT DATE: 04/13/2022
NARRATIVE
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On 10/28/21 at 12:17 pm, LPA interviewed S3. S3 stated that “Two weeks ago, S1 was yelling at clients to ‘sit here and eat your food,” and S3 told the supervisor. On 10/28/21 at 12:31 pm, LPA inquired with S4. S4 describes S1 as “new to the job, one year” and that S1 “has said loudly to clients ‘eat your breakfast, take your toothbrush,” in a frustrated tone. S4 mentioned the incident to the supervisor. On 10/28/21 at 12:51 pm, LPA spoke with S5 who explains that S1 has a high tone and S5 has had to remind S1 how to talk with residents. S5 said S1 has gotten frustrated and S5 has talked with S1 five times and written-up S1 once. S5 says S1 is no longer employed with the facility effective 10/25/21.

On 11/02/21 at 9:00 am, LPA inquired with S6. S6 expresses that S6 recalls seeing S1 “forcing Resident #2’s (R2) head back, cursing and yelling at R2.” S6 states they spoke with the supervisor a few weeks prior regarding S1’s being “rough with clients.” On 11/04/21 at 1:15 pm, a credible Witness #1 (W1) asked S1 if S1 ever gets frustrated or pushes S1’s patience, and S1 replied “No, it’s not their fault.” LPA asked S1 if S1 has ever seen other staff yell or get rough with residents, and S1 says they have not heard anyone yell at residents and as far as getting rough, S1 says “No, I would report it to the supervisor.”

On 4/13/22, LPA reviewed facility records. Records indicate that S1 was counseled and written up for acting inappropriately with residents in care.

Based on interviews, the allegation that “Staff yell at residents,” is deemed Substantiated at this time. Interviews with staff show that S1 has been observed speaking to residents in a loud, frustrated tone. S1 has also been counseled on this behavior.

A copy of the report, deficiency, and appeal rights emailed to the administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 29-AS-20211022094417
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: C.A.L.L.-CARMELITA HOUSE
FACILITY NUMBER: 405801701
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/18/2022
Section Cited
CCR
87468.1(a)(1)
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87468.1(a)(1) Personal Rights to Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement was not as evidenced by:
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Licensee has agreed to implement greater screening measures prior to hiring staff. Administrator will conduct training on Reg. 87468.1 Personal Rights of Residents in All Facilities with staff and send the sign-in training sheet to CCL by 4/18/22.
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Based on interviews and record review, the licensee did not ensure the personal rights of residents in care. S1 was speaking to residents in an unsafe manner which posed a potential health, safety, and personal rights risk to residents in care.
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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: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/22/2021 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20211022094417

FACILITY NAME:C.A.L.L.-CARMELITA HOUSEFACILITY NUMBER:
405801701
ADMINISTRATOR:COURTNEY MOOREFACILITY TYPE:
740
ADDRESS:2660 FERROCARRILTELEPHONE:
(805) 466-8502
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:6CENSUS: 6DATE:
04/13/2022
UNANNOUNCEDTIME BEGAN:
03:52 PM
MET WITH:ReginaTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff caused injury to resident.
Staff handled residents in a rough manner.
Staff do not report incidents.
Resident's dental needs are not being met.
Residents do not receive PRN in a timely manner.
INVESTIGATION FINDINGS:
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On the allegation “Staff caused injury to resident,” the complainant’s concern was that Staff #1 (S1) had handled Resident #1 (R1) in a rough manner causing an injury to R1. Complainant states that on the evening/NOC shift of 10/21/21, staff observed S1 grabbing R1 on the upper right arm area in a rough manner and in the morning of 10/22/21, R1 had bruising on the same area. To investigate the allegation, LPA made observations, interviewed complainant and staff, and attempted to interview residents, and reviewed documentation.

On 10/22/21 at 1:12 pm, LPA visited the facility. LPA was unable to observe the suspected injury area due to Resident #1 (R1) being taken to the hospital for the condition. On 10/28/21 at 1:20 pm, LPA visited the facility and attempted to view R1’s upper right arm. R1 was not cooperative when staff tried to lift R1’s arm, and LPA was unable to see any condition on R1’s arm. LPA attempted to interview residents, however, residents present were nonverbal.
Continued on 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 29-AS-20211022094417
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: C.A.L.L.-CARMELITA HOUSE
FACILITY NUMBER: 405801701
VISIT DATE: 04/13/2022
NARRATIVE
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On 10/22/21 at 1:12 pm, LPA interviewed Staff #2 (S2). S2 says that R1 was “taken to the hospital this morning” due to a bruise on R1’s right upper arm between the elbow and shoulder on the under part of the arm. S2 says R1 “has a bruise 8 inches long and 4 inches wide, and it is swollen.” S2 says R1 bruises easily because R1 is anemic. S2 informed the supervisor about the bruising on 10/21/21 at 6:30 pm when S2 noticed it while giving R1 an evening shower. S2 described the bruise as “purple-blueish, a rich purple color” and said it was a new bruise. S2 explained that R1 is “nonverbal, but makes noises to communicate.” S2 asked R1 if it hurt, and R1 responded by nodding “yes.”

On 10/28/21 at 12:17 pm, LPA interviewed Staff #3 (S3). S3 says that on 10/21/21, at 2:45 pm, S3 changed R1’s shirt and did not see any markings on R1’s right upper arm underside. S3 says on 10/22/21 at 6:50 am, S3 looked at R1’s arm and “knew it was cellulitis, not a bruise.”

On 10/28/21 at 12:31 pm, LPA interviewed Staff #4 (S4). S4 says that on Friday morning, 10/22/21, S4 saw the marks on R1’s arm and “did not know what the marks are.”

On 10/28/21 at 12:51 pm, LPA interviewed Staff #5 (S5). S5 said that on Thursday, 10/21/21 between 7:00 pm and 8:00 pm, S2 called S5 and informed that R1 had a “rash, bruising on the arm”, but showed no signs of pain. On Friday morning, 10/22/21, S5 says they took R1 to the ER and told ER staff that R1 has “an arm injury and rash.” S5 says S5 thought it might be a bruise as it was swollen. S5 said the hospital gave R1 a 10-day antibiotic and “immediately the bruising went away.”

On 11/04/21 at 1:00 pm, LPA spoke with S1. S1 says S1 has never been aggressive with residents and didn’t think it was a bruise on R1’s arm, but rather that “it looked like cellulitis” and described it as looking “red, swollen, hot to the touch, and about 6-7 inches under the arm to elbow.”

On 4/04/22 at 5:00 pm, LPA reviewed hospital records for R1’s visit on 10/22/21. On 10/22/21 at 9:50 am, R1 was seen at the hospital for “redness, bruising and pain to the right upper arm.” The hospital visit summary states “unknown if it is an injury.” The diagnosis was listed was an arm injury, Cellulitis, and Hyponatremia. The ER physician notes that the right upper arm has tenderness, bruising and redness, no wounds. R1 was given an antibiotic and prescribed an antibacterial medication. LPA reviewed photos taken by staff of R1’s right upper arm.



Continued on 9099-C.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 29-AS-20211022094417
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: C.A.L.L.-CARMELITA HOUSE
FACILITY NUMBER: 405801701
VISIT DATE: 04/13/2022
NARRATIVE
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LPA reviewed photos taken by staff of R1’s right upper arm. LPA reviewed the photos and observed that on 10/22/21, R1 had a red sporadic marking on the upper inside arm with a length of about seven inches and a width of approximately four inches. In the crease of R1’s arm on the opposite side of the elbow, there was a gray patch approximately three inches by three inches. In the 10/25/21 photo, R1’s upper inside arm shows dark pink coloring in four patches from the shoulder to the elbow. In the 11/01/21 photo, there is a patch of pale redness near the elbow under the arm. The bruising is no longer visible.

Based on the evidence obtained, the allegation that “Staff caused injury to resident” is deemed Unsubstantiated at this time. R1 had markings on their upper inside right arm, however, it is not clear that the bruising and redness was caused by staff. R1 had a sensitivity for bruising and history of cellulitis.

On the allegation “Staff handled residents in a rough manner,” the complainant’s concern was that R1 was being mishandled by S1. Complainant stated that staff observed S1 being rough with R1 on 10/21/21, and that staff witnessed S1 attempting to “force” R1’s arm to put deodorant on R1. To investigate the allegation, LPA interviewed the complainant and staff, and attempted to interview resident.

LPA interviewed S1, S2, S3, S4, and S5 from 10/22/21 through 11/04/21. Interviews reveal that staff did not observe the incident and have not seen any staff handle residents in a rough manner.

On 10/28/21 at 1:20 pm, LPA attempted to interview R1, however, R1 was nonverbal.

Based on interviews, the allegation “Staff handled residents in a rough manner,” is Unsubstantiated at this time. The testimony given by the staff shows that staff do not mishandle residents.

Regarding the allegation “Staff do not report incidents,” the complainant was concerned that there was an incident on 10/21/21 that was not reported by S1. To investigate the allegation, LPA reviewed facility records and interviewed staff.



On 10/23/21 at 11:12 am, CCL received an incident report from the facility reporting that, “On 10/21 during R1’s PM shower staff noticed a red rash with some bruising on R1’s upper inner arm of approximately 8 inches in length and 4 inches in width, it was hot to the touch. In the morning symptoms were worsening.” The report states R1 was taken to the emergency room and the diagnosis was cellulitis.
Continued on 9099-C,.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 29-AS-20211022094417
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: C.A.L.L.-CARMELITA HOUSE
FACILITY NUMBER: 405801701
VISIT DATE: 04/13/2022
NARRATIVE
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On 10/28/21 at 12:17 pm, LPA spoke with S3 who stated that when an incident occurs at the facility, S3 writes an incident report and gives it to the supervisor. On 11/02/21 at 9:00 am, LPA interviewed S6 who said S6 has not seen or heard of S1 creating incident reports and had not seen one for the situation on 10/21/21 with R1. On 11/04/21 at 1:00 pm, LPA spoke with S1 who stated that S1 “has filled out incidents reports” and recalls “twice, once when a resident fell, and I don’t remember the other time.”

On 4/12/22 at 11:39 am, LPA reviewed incident reports submitted by staff and reported to CCL. Between 7/1/21 and 10/31/21, staff submitted four incident reports to management. Between 1/11/21 and 11/04/21, the facility sent fourteen incident reports to CCL. Records show that staff did not submit an incident report for the incident on 10/21/21; however, management did report the incident to CCL.



Based on interviews and record review, the allegation that “Staff do not report incidents,” is deemed Unsubstantiated at this time. Staff interviews reveal that staff are expected to complete incident reports as part of their job. Records review indicates that incidents reports are being written and sent to CCL.

Regarding the allegation, “Resident's dental needs are not being met,” the complainant was concerned that Resident #3 (R3) had chipped and jagged teeth that were “stubs.” The complainant showed concern that R3 was in pain and states that when staff try to brush R3’s teeth, R3 kicks them or tries to run away. To investigate the allegation, LPA reviewed records and interviewed staff and witnesses.



On 4/12/22 at 11:02 am, LPA reviewed R3’s dental records. Records indicate that a dental hygienist went to the facility on 5/07/21 to perform an oral evaluation and dental cleaning. Hygienist records show that R3 has “no visible cavities” and recommended R3 see a doctor at the next “annual” exam. On 9/25/21, a hygienist visited R3 at the facility again and documented that R3 had a cavity and recommended that R3 see a dentist “ASAP.” On 4/02/22, R3 was seen again by a hygienist at the facility. The hygienist applied silver diamine fluoride (SDF) to stop the decay, noted that a second tooth had a cavity, and recommended R3 see a dentist at the next “annual exam.” Facility records indicate that R3’s most recent dental exam occurred on 2/11/20.

On 4/12/22 at 2:04 pm, LPA spoke with Witnesses #2 and #3 (W2 and W3) who confirmed that dental hygienists visited the facility on 5/07/21, 9/25/21 and 4/02/22 to conduct an oral evaluation and dental cleaning on R3. They clarified that the hygienist does a visual evaluation and there are no x-rays. W1and W2 explained that during the pandemic, dentists were not seeing patients and that now, dentists are backed-up with patients. They also stated that there are only two dentists in the area that work with “this population” because the residents have a hard time with examinations and procedures, and many times have to be placed under anesthesia. Continued on 9099-C.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 29-AS-20211022094417
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: C.A.L.L.-CARMELITA HOUSE
FACILITY NUMBER: 405801701
VISIT DATE: 04/13/2022
NARRATIVE
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On 4/12/22 at 4:01 pm, LPA spoke with S5 who stated that S5 contacted a dentist on 11/23/21 to make an appointment for R3. The dentist would not see R3 due to R3’s age. The dentist’s office stated “it would be too much of a liability to put R3 under sedation.” On 4/12/22, S5 called R3’s dentist again, and R3 is scheduled for a consultation in July 2022.

Based on evidence obtained, the allegation, “Resident's dental needs are not being met,” is deemed Unsubstantiated at this time. Due to the pandemic, facility staff were unable to schedule a dental appointment for R3, yet R3 was seen three times in the past year by dental hygienists. The facility took appropriate measures to address R3’s dental needs by having hygienists evaluate and provide cleanings.

Regarding the allegation, “Residents do not receive PRN in a timely manner,” the complainant showed concern that staff did not receive a timely response when phoning a supervisor to get approval to give PRNs to residents. Complainant stated that R1 often screams and that staff tried several times to get a hold of the supervisor. Complainant said R1 had to wait two hours for PRNs because the supervisor did not respond in a timely manner. To investigate the allegation, LPA interviewed staff.



On 10/28/21 at 12:17 pm, LPA Chavez interviewed S3 who stated that the procedure for when a client needs a PRN is that S3 calls the supervisor for permission. S3 says the supervisor responds “usually within two to three minutes.” S3 said if the supervisor doesn’t respond, S3 calls the Lead. On 10/28/21 at 12:31 pm, LPA Chavez conversed with S4 who relayed that S4 observes residents’ needs and calls the supervisor, if a client needs a PRN.” On 11/04/21 at 1:00 pm, S1 said that when a resident needs a PRN, S1 evaluates the behavior to see if they’re agitated or anxious, and if so, for more than 20-30 minutes, S1 notifies the supervisor and explains the behavior. S1 said “most times, the supervisor responds instantly.” S1 says occasionally S1 will not get a response within “10-15 minutes” and then S1 texts the lead. S1 relays “this happened maybe once.”

Based on the evidence obtained, the allegation, “Residents do not receive PRN in a timely manner,” is deemed Unsubstantiated at this time. Staff interviews reveal that the supervisor typically responds in a timely manner to staff requests for PRNs. When the supervisor is unavailable, a back-up lead is available.

Exit interview conducted and a copy of report emailed to the administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022
LIC9099 (FAS) - (06/04)
Page: 8 of 8