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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405801701
Report Date: 10/29/2024
Date Signed: 10/29/2024 02:06:10 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
12/29/2023 and conducted by Evaluator Melisa Rankin
COMPLAINT CONTROL NUMBER: 29-AS-20231229115806
FACILITY NAME:C.A.L.L.-CARMELITA HOUSEFACILITY NUMBER:
405801701
ADMINISTRATOR:VALERIE BRAISHER KINGFACILITY TYPE:
740
ADDRESS:2660 FERROCARRILTELEPHONE:
(805) 466-8502
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:6CENSUS: 6DATE:
10/29/2024
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Joni ChapmanTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff hit, and or pushed and or yelled at residents in care.
Resident fell due to staff not assisting resident appropriately.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Joni Chapman and explained the purpose of the visit. During the initial visit on 1/4/2024 from 2:00pm to 5:10pm, LPA De Leon toured the facility and interviewed staff and residents, and obtained relevant documents.

On the allegation: Staff hit, and or pushed and or yelled at residents in care. It was alleged Staff 1 (S1) tells residents to shut up, hit Resident 1 (R1)’s hand, and yelled at R1. It was also alleged S1 was abusive to R1 in the shower by pushing them.

Multiple staff interviewed stated they have heard S1 yell at residents, particularly R1 and R2. One staff stated S1 tells residents to shut up. Staff confirmed the bathroom incident occurred where S1 yelled at R2 in the shower.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
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 29-AS-20231229115806
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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: 10/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/30/2024
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4) Personal Rights. To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in...qualifications, and competency to meet their needs.
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Facility will ensure all staff attend a training focused on Resident Personal Rights. Facility will provide CCL with copy of training agenda as well as a sign in sheet for all staff who attended the training.
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This requirement was not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above when S1 deviated from protocol and had R2 sit on their
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walker, resulting in a fall, which posed an immediate safety risk to residents in care.
Type A
10/30/2024
Section Cited
CCR
87468.1(a)(1)
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87468.1(a)(1) Personal Rights. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff,... This requirement was not met as
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Facility will ensure all staff attend a training focused on Resident Personal Rights. Facility will provide CCL with copy of training agenda as well as a sign in sheet for all staff who attended the training.
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evidenced by: Based on record review and interview, the licensee did not comply with the section cited above when S1 yelled at residents in care, which posed 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: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20231229115806
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: C.A.L.L.-CARMELITA HOUSE
FACILITY NUMBER: 405801701
VISIT DATE: 10/29/2024
NARRATIVE
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Multiple staff interviewed stated they have observed S1 slamming cupboards, which was disruptive to residents. Staff also stated S1 has argued with them in front of clients, after refusing to help with tasks that would assist clients, such as retrieving yogurt for a resident that had a cough. One Agency staff, a Certified Nursing Assistant (CNA), interviewed stated they had not witnessed either incident, and had not seen or heard S1 yell, hit or scream at a resident, but had heard of things happening from other staff.

Multiple staff stated S1 gets rude and defensive when other staff intervene and inform S1 their behavior is inappropriate. Multiple staff stated they informed the supervisor after witnessing the incidents and inappropriate behavior from S1. Staff asked the manager if S1 could cover different clients in the facility that are more independent than the ones S1 was currently assisting, and this was enacted. Staff stated R1 and R2 get very agitated when S1 is on shift following the incidents.

On the allegation: Resident fell due to staff not assisting resident appropriately. It was alleged when assisting Resident 2 (R2) at the dining table, S1 did not properly assist R2 and allowed R2 to fall, when the fall could have been prevented.

One staff stated they were a witness to the fall incident on 12/26/2023 with S1 and R2. R2 uses a walker, and staff interviewed stated they need to make sure the chair is stable before R2 sits down. S1 was in charge of care for R2 and was getting R2 to the dining table. R2 typically sits in a chair at the dining table, but on this occasion, S1 had R2 stand up holding onto the table and repositioned R2’s walker backwards to sit on. R2 lost their balance and started to stumble, and other staff present believed S1 could have prevented the fall from occurring by assisting R2 to slide down instead of fall, but S1 backed away and instead let R2 fall. Another agency staff, a Certified Nursing Assistant (CNA), on duty went over to assist, and S1 tried to sit R2 on the walker again. The CNA instructed S1 to get a real chair for R2. Another staff went to assess R2 after the fall to ensure they were walking ok. R2 was not hurt in this incident. Staff stated after this incident, S1 does not work with R2 due to being “neglectful in [their] duties.”
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20231229115806
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: C.A.L.L.-CARMELITA HOUSE
FACILITY NUMBER: 405801701
VISIT DATE: 10/29/2024
NARRATIVE
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The Administrator at the time confirmed these two separate incidents with S1 occurred, on different days. The shower incident occurred around 12/10/2023-12/15/2023 and the fall incident with R1 occurred on 12/26/23. There is camera footage of the chair incident but not the bathroom incident. Administrator stated at first they thought there was not enough evidence to prove the bathroom incident occurred, until another staff stated they witnessed the incident. Then they reported the incident to Corporate.

Administrator stated they counseled S1 on 12/28/2023 about their behavior. Supervisor stated S1 was not being left alone with residents and other staff were present supervising after the incident. Administrator and supervisor stated S1 was a new staff and had been written up multiple times. The first write-up was on 12/15/2023 for yelling at R2 in the shower and arguing with another staff loudly in the presence of residents. S1 also received a write-up for the chair incident.

Based on the information obtained, both allegations are deemed Substantiated at this time.

Exit interview, deficiencies cited on 9099-D, report given, appeal rights given.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4