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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405801701
Report Date: 12/22/2022
Date Signed: 12/22/2022 04:10:28 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
08/02/2022 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20220802165129
FACILITY NAME:C.A.L.L.-CARMELITA HOUSEFACILITY NUMBER:
405801701
ADMINISTRATOR:BRENDA VICTORIAFACILITY TYPE:
740
ADDRESS:2660 FERROCARRILTELEPHONE:
(805) 466-8502
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:6CENSUS: 5DATE:
12/22/2022
UNANNOUNCEDTIME BEGAN:
03:18 PM
MET WITH:Brenda Victoria, AdministratorTIME COMPLETED:
04:27 PM
ALLEGATION(S):
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Staff did not follow resident's special diet
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Chavez conducted a subsequent complaint visit to deliver final findings for the above allegation. The initial complaint visit was conducted on 08/03/2022 by LPA Chavez. During today’s visit, LPA met with Brenda Victoria, Administrator, and explained the reason for the visit.

On 08/02/2022, the Department received a complaint regarding an allegation of Staff did not follow resident's special diet. It was alleged that staff did not follow Client #1 (C1’s) special diet plan when they took C1 to the fair on 07/25/2022 and allowed C1 to have food and drink which was not pureed or thickened, as was prescribed.

On 08/03/2022, the Department referred the complaint to the Community Care Licensing Investigations Branch (IB) and Special Investigator Assistant Monica Lopez, was assigned to obtain a death certificate, medical records and hospice records. On 08/29/2022, the complaint referral was upgraded to a full investigation and was assigned to Investigator Romelia Munoz to investigate the allegations of questionable death and staff not following C1’s special diet plan. Continued on 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
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 7
Control Number 29-AS-20220802165129
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: 12/22/2022
NARRATIVE
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On 08/03/2022, between 12:22pm and 3:30pm, LPA Chavez conducted an unannounced 24-hour complaint visit. The LPA met with Brenda Victoria, Administrator, and informed the reason for the visit.
During the visit, the LPA interviewed the Administrator, reviewed records and obtained pertinent copies of facility records. LPA explained that further investigation was needed. The Administrator was notified that the case was referred to Community Care Licensing Investigation's Branch (IB) for further investigation.

Investigator Munoz conducted interviews on 09/26/2022, at approximately 10:47am, with facility staff; on 09/27/2022, at approximately 9:32am, with C1’s primary medical doctor; on 10/18/2022, from approximately 9:45am to 12:45pm, with the Administrator and staff; on 11/10/2022, at approximately 2:50pm, with staff; on 11/14/2022, at approximately 9:00am, with staff; and on 11/15/2022, at approximately 9:45am, with C1’s resident representative. Additionally, the Investigator reviewed copies of Twin Cities Community Hospital medical records, Central Coast Hospice records and facility documents related to C1.

The physician report dated 06/04/2021 lists C1’s diagnoses as Developmental Delay, Autism, and special diet pureed with thickened liquids. C1’s Individual Service Plan (ISP) dated 05/11/2022, also indicates C1 is dysphagic and requires a pureed, level II dysphagic diet.

The investigation revealed that on 07/25/2022, Staff #1 (S1) took C1 to the fair. S1 allowed C1 to drink soda without Thick It powder and have a few bites of non-pureed hot dog. The soda and food were not thickened or pureed, as was prescribed by the doctor due to C1’s dysphagia. On 07/26/2022, at 11:38am, C1 began making gurgling sounds, vomited, and was sent to the Emergency Room. C1 was discharged the same day with a diagnosis of possible viral gastritis and prescribed nausea medication.

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

DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20220802165129
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: 12/22/2022
NARRATIVE
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On 07/27/2022, at 11:49am, C1 returned to the hospital for ongoing vomiting and difficulty breathing. C1 had low oxygen saturations and coarse breath sounds. C1’s x-ray showed slight haziness to the right upper lung. The doctors discussed the patient plan with C1’s resident representative who requested C1 be placed on comfort care. On 07/30/2022, C1 was discharged back to the facility on hospice care. C1’s discharge diagnoses included acute hypoxic respiratory failure, aspiration pneumonitis, seizure disorder, developmental delay and comfort care. C1 was placed on Central Coast Hospice care at the facility with the diagnosis of acute hypoxemic respiratory failure. On 07/31/2022, at 10:20pm, C1 stopped breathing and became unresponsive. Staff contacted the hospice nurse to report the death.

Copies of C1’s service plan and facility demographic sheet stated C1 was a severe choking hazard and C1 is dysphagic which required C1 to be on a pureed diet. All staff interviewed had knowledge of C1’s pureed diet plan. However, multiple staff confirmed that C1 had a bite of a non-pureed hot dog and sips of soda while at the fair on 07/25/2022. The administrator stated that the staff also gave C1 a dime size pieces of funnel cake and did not bring C1’s Thick It powder to the fair.

Based on the statements provided and documentation obtained, the Department has sufficient evidence to support the allegation Staff did not follow resident's special diet. Therefore, the allegation is deemed Substantiated at this time.

A $500 immediate civil penalty is assessed today. The administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f).

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D).

Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report emailed to the executive director and administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 29-AS-20220802165129
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: 12/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/23/2022
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents…shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
This requirement is not met as evidenced by:
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Licensee will submit a plan to ensure that staff have ongoing training in following individual resident diet plans and submit the plan to CCL by 12/23/22.
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Based on interviews and records review, the licensee did not comply with the section cited above. On 07/25/2022, staff did not follow C1’s special diet plan by giving C1 soda without Thick It powder and a non-pureed hot dog, which posed an immediate health and safety 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: 12/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
08/02/2022 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20220802165129

FACILITY NAME:C.A.L.L.-CARMELITA HOUSEFACILITY NUMBER:
405801701
ADMINISTRATOR:BRENDA VICTORIAFACILITY TYPE:
740
ADDRESS:2660 FERROCARRILTELEPHONE:
(805) 466-8502
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:6CENSUS: 5DATE:
12/22/2022
UNANNOUNCEDTIME BEGAN:
03:18 PM
MET WITH:Brenda Victoria, AdministratorTIME COMPLETED:
04:27 PM
ALLEGATION(S):
1
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Questionable Death
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Chavez conducted a subsequent complaint visit to deliver final findings for the above allegation. The initial complaint visit was conducted on 08/03/2022 by LPA Darlene Chavez. During today’s visit, LPA met with Brenda Victoria, Administrator, and explained the reason for the visit.

On 08/02/2022, the Department received a complaint regarding an allegation of questionable death. It was alleged that staff did not follow Client #1 (C1’s) special diet plan which led directly to C1’s death. The Department referred the complaint to the Community Care Licensing Investigations Branch (IB) and Special Investigator Assistant Monica Lopez, was assigned to obtain a death certificate, medical records and hospice records. On 08/29/2022, the complaint referral was upgraded to a full investigation and was assigned to Investigator Romelia Munoz to investigate the allegation of questionable death.

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

DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 29-AS-20220802165129
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: 12/22/2022
NARRATIVE
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On 08/03/2022, between 12:22pm and 3:30pm, LPA Chavez conducted an unannounced 24-hour complaint visit. The LPA met with Brenda Victoria, Administrator, and informed the reason for the visit.
During the visit, the LPA interviewed the Administrator, reviewed records and obtained pertinent copies of facility records. LPA explained that further investigation was needed. The Administrator was notified that the case was referred to Community Care Licensing Investigation's Branch (IB) for further investigation.

Investigator Munoz conducted interviews on 09/26/2022, at approximately 10:47am, with facility staff; on 09/27/2022, at approximately 9:32am, with C1’s primary medical doctor; on 10/18/2022, from approximately 9:45am to 12:45pm, with the Administrator and staff; on 11/10/2022, at approximately 2:50pm, with staff; on 11/14/2022, at approximately 9:00am, with staff; and on 11/15/2022, at approximately 9:45am, with C1’s resident representative. Additionally, the Investigator reviewed copies of Twin Cities Community Hospital medical records, Central Coast Hospice records and facility documents related to C1.

The physician report dated 06/04/2021 lists C1’s diagnoses as Developmental Delay, Autism, and special diet pureed with thickened liquids. C1’s Individual Service Plan (ISP) dated 05/11/2022, also indicates C1 is dysphagic and requires a pureed, level II dysphagic diet.

The investigation revealed that on 07/25/2022, Staff #1 (S1) took C1 to the fair. S1 allowed C1 to drink soda without Thick It powder and have a few bites of non-pureed hot dog. The soda and food were not thickened or pureed, as was prescribed by the doctor due to C1’s dysphagia. On 07/26/2022, at 11:38am, C1 began making gurgling sounds, vomited, and was sent to the Emergency Room. C1 was discharged the same day with a diagnosis of possible viral gastritis and prescribed nausea medication.

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

DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20220802165129
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: 12/22/2022
NARRATIVE
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On 07/27/2022, at 11:49am, C1 returned to the hospital for ongoing vomiting and difficulty breathing. C1 had low oxygen saturations and coarse breath sounds. C1’s x-ray showed slight haziness to the right upper lung. The doctors discussed the patient plan with C1’s resident representative who requested C1 be placed on comfort care. On 07/30/2022, C1 was discharged back to the facility on hospice care. C1’s discharge diagnoses included acute hypoxic respiratory failure, aspiration pneumonitis, seizure disorder, developmental delay and comfort care. C1 was placed on Central Coast Hospice care at the facility with the diagnosis of acute hypoxemic respiratory failure. On 07/31/2022, at 10:20pm, C1 stopped breathing and became unresponsive. Staff contacted the hospice nurse to report the death.

C1’s death certificate listed the immediate cause of death as acute hypoxic respiratory failure with conditions leading to the cause of death as aspiration pneumonia and oropharyngeal dysphagia. The Twin Cities Community Hospital records noted C1 was initially seen for nausea and vomiting. C1 was discharged and later returned for continued vomiting and trouble breathing. C1 was diagnosed with acute hypoxic respiratory failure and aspiration pneumonitis, likely caused by ongoing vomit. C1’s primary medical doctor stated Thick It mix was prescribed to assist C1 with food texture due to swallowing difficulty and it was to be taken as directed. The doctor stated that there is a possibility that if staff gave C1 a drink without the Thick It, C1 could have developed a cough and it may have contributed, but he did not believe this would have been the cause of death.

Based on the statements provided and documentation obtained, the Department does not have sufficient evidence to support the allegation Questionable Death. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted and a copy of this report emailed to the executive director and administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7