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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 01:47:28 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
08/14/2023 and conducted by Evaluator Melisa Rankin
COMPLAINT CONTROL NUMBER: 29-AS-20230814164102
FACILITY NAME:C.A.L.L.-CARMELITA HOUSEFACILITY NUMBER:
405801701
ADMINISTRATOR:KYLAN REYNOSOFACILITY TYPE:
740
ADDRESS:2660 FERROCARRILTELEPHONE:
(805) 466-8502
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:6CENSUS: 6DATE:
10/29/2024
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Joni ChapmanTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff do not accord dignity to resident(s) in care.
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 8/18/2023 from 10:10am to 12:05pm, LPA Chavez toured the facility, interviewed staff, and obtained relevant documents. On 9/7/2023 at 9:02am, LPA interviewed Executive Director (ED) regarding video footage in the facility. ED stated they reviewed footage for dates 8/3/2023 through 8/9/2023, and the system did not go back further.

On the allegation: Staff do not accord dignity to resident(s) in care. It was alleged a staff (Staff 1 – S1) spoke inappropriately to clients. On 6/17/2023, S1 allegedly told Client 1 (C1) “I don’t give a f---” and “shut the f--- up.” It was also alleged S1 yells at clients and makes them feel bad if they have incontinence episodes.
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 3
Control Number 29-AS-20230814164102
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 B
11/12/2024
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 evidenced by:
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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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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 3
Control Number 29-AS-20230814164102
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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 Administrator stated a different on-call staff “had a bit of attitude,” and was “short” with clients and not the most patient. However, this staff never “lashed out” at clients. Another staff stated one staff is “sometimes pushy and firm but cares for clients.” Administrator stated there was one instance where a staff was sitting at the kitchen counter and C1 was telling a story, and the staff just walked away and did not listen to C1. Administrator stated S2 was not caring about the quality of care and was let go due to performance issues. Based on the information obtained, the allegation is 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: 3 of 3