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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405801701
Report Date: 05/20/2022
Date Signed: 05/25/2022 06:43:16 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
04/26/2021 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20210426110427
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:
05/20/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Brenda Victoria/AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility failed to notify resident's authorized representative of incident.
INVESTIGATION FINDINGS:
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 At 2:00pm on 05/20/2022, Licensing Program Analyst (LPA) Jeffries conducted a subsequent complaint visit to deliver final findings of the complaint investigation. LPA met with House Manager Brenda Victoria and explained the purpose of the visit.

LPA De Leon conducted the initial visit and requested documentation on 04/27/2021. LPA De Leon received and reviewed documentation on 04/28/2021. LPA De Leon received additional medical records from Twin Cities Hospital on 03/30/2022. LPA conducted interviews with witnesses on 04/26/2021 at 2:57 PM, 04/28/2021 at 2:37 PM, 04/28/2021 at 2:41 PM, 04/29/2022 at 3:30 PM, and on 05/18/2022 at 3:09 PM. LPA interviewed staff on 05/19/2022 at 3:13 PM, 3:40 PM, 3:58 PM and 4:10 PM. LPA thoroughly reviewed records on 05/19/2022 at 4:15pm.

CONTINUED on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
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 5
Control Number 29-AS-20210426110427
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: 05/20/2022
NARRATIVE
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On the allegation: Facility failed to notify resident's authorized representative of incident. LPA conducted interviews with staff and Resident 1 (R1)’s responsible parties. LPA also reviewed facility records including incident reports. The investigation revealed that R1 had responsible parties to contact after an incident, and documentation does not reveal all parties were contacted regarding R1’s fall incident on 2/23/2021. Therefore, the allegation is deemed Substantiated at this time.

Exit interview conducted, deficiency cited, copy of report and appeal rights emailed to Administrator/Licensee.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5
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
04/26/2021 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20210426110427

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: DATE:
05/20/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Brenda Victoria/AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Due to staff neglect, resident sustained fracture while in care.
INVESTIGATION FINDINGS:
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At 2:00pm on 05/20/2022, Licensing Program Analyst (LPA) Jeffries conducted a subsequent complaint visit to deliver final findings of the complaint investigation. LPA met with House Manager Brenda Victoria and explained the purpose of the visit.

LPA De Leon conducted the initial visit and requested documentation on 04/27/2021. LPA De Leon received and reviewed documentation on 04/28/2021. LPA De Leon received additional medical records from Twin Cities Hospital on 03/30/2022. LPA conducted interviews with witnesses on 04/26/2021 at 2:57 PM, 04/28/2021 at 2:37 PM, 04/28/2021 at 2:41 PM, 04/29/2022 at 3:30 PM, and on 05/18/2022 at 3:09 PM. LPA interviewed staff on 05/19/2022 at 3:13 PM, 3:40 PM, 3:58 PM and 4:10 PM. LPA thoroughly reviewed records on 05/19/2022 at 4:15pm.

CONTINUED on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20210426110427
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: 05/20/2022
NARRATIVE
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On the allegation: Due to staff neglect, resident sustained fracture while in care. LPA interviewed witnesses, staff and reviewed medical records and incident report which revealed Resident 1 (R1) had a fall on 2/23/2021. Facility supervisor was immediately notified and R1 was take to the Emergency Room, where R1 was diagnosed with Intertrochanteric fracture of the right hip and scheduled for surgery the next day. No evidence was found during the investigation to suggest that staff neglected the resident, resulting in a fall. Staff sought immediate medical treatment for R1 when the fall occurred. Therefore, the allegation is deemed Unsubstantiated at the time.

Exit interview conducted and copy of report emailed to Administrator/Licensee.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20210426110427
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: 05/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/27/2022
Section Cited
CCR
87468.1(a)(8)
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Personal Rights of Residents in All Facilities (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(8)To have their representatives regularly informed by the licensee of activities
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Administrator updated resident identification and emergency information records to include all residents contacts to notify. Administrator agreed to train staff on 87468.1 personal rights and incident reporting requirements, send copy of training with staff signatures to CCL.
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related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement was not met as evidenced by: Based on witness interviews and documentation the Licensee did not comply with the regulation above and did not notify R1’s representatives of R1’s fall which poses a potential 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: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5