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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405801701
Report Date: 01/29/2025
Date Signed: 01/29/2025 12:53:28 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
01/19/2024 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20240119110310
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: 4DATE:
01/29/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Isabel Lopez, SupervisorTIME COMPLETED:
12:55 PM
ALLEGATION(S):
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Licensee does not ensure the administrator is on the premises for a sufficient number of hours to manage the facility
Staff do not ensure residents are taken to medical and dental appointments
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above. LPA met with Isabel Lopez, Supervisor and explained the purpose of the visit.

LPA De Leon conducted the 10-day complaint visit on 01/26/2024 and collect records. LPA conducted interviews with Staff on 01/22/2025 at 1:30pm, 2:30pm, and 2:45pm. LPA De Leon conducted additional staff interviews on 01/28/2025 at 1:31pm, 2:20pm, 2:57pm and 3:59pm. LPA asked to review R1 and R2's charting records for 2024 upon arrival to the facility today.

On the allegation: Licensee does not ensure the administrator is on the premises for a sufficient number of hours to manage the facility. LPA conducted staff interviews and reviewed facility schedules and records which revealed the administrator on record was not the administrator at the facility.
Continued 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
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-20240119110310
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: 01/29/2025
NARRATIVE
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The facility had high turn over and was not staffed with a lead/supervisor or Administrator several times throughout 2024. The Administrator on record did check in at the facility but did not have set schedule to spend time at the facility on a regular bases. The Administrators are assigned to homes to meet the administrator requirement but do not work at some of the homes regularly to oversee the business operation. The lead/Supervisor position is the staff that is scheduled at the home regularly but during the 2024 year this position had high turnover and staff was not in this home regularly to oversee the staff, residents, and business operation. Due to not having Administrator or lead/supervisor the facility was not getting the job duties of these position done creating staff to have to notify them of residents needs and not getting timely attention of those residents needs. The medical records and paperwork were not getting completed which led to staff not having important paperwork and records when needed. Based on the evidence this allegation is Substantiated at this time.

On the allegation: Staff do not ensure residents are taken to medical and dental appointments. LPA interviewed staff and reviewed resident’s records which revealed staff did notify leads/supervisors/administrator of the need for medical and dental appointments for residents in care. Due to high turned over and not having the staff available to arrange these appointments timely so appointments did not get made timely, some appointments were made but several months out which did not address the needs of the residents timely and some appointments had to be rescheduled. The staff did not follow up on medical and dental issues in a timely matter for some of the residents in care. Based on the evidence this allegation is Substantiated at this time.

Exit interview conducted, deficiencies cited, copy of report and appeal rights printed for Supervisor.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20240119110310
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: 01/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/05/2025
Section Cited
CCR
87405(a)
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(a)All facilities shall have a qualified and currently certified administrator....shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility...This requirement was not met as evidenced by:
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Licensee agreed to review and have a statement of understanding in Regulation 87405 and train all staff in the regulation requirements and provide proof of training and an updated LIC 500 to CCL.
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Based on staff interview and record review the Licensee did not comply with the regulations above, Administrators or back up were not on the premises, to permit adequate attention to the management or administration of the facility operations which possess a potential health, safety, and personal rights risk to residents in care.
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Type B
02/05/2025
Section Cited
CCR
87468.1(a)(16)
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(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16)To receive or reject medical care or other services. This requirement was not met as evidenced by
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Licensee agreed to, review charting notes from staff daily and make appointments immediately for residents when they need them, provide a statement of understanding to CCL as well as review and train all staff on 87468.1 and 87468.2 Personal Rights regulations.
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Based on staff interviews and charting records the Licensee did not comply with the regulation above Resident were not taken to see a doctor/dentist in a timely matter when medical/dental service were needed which poses a potential health, safety, and personal rights risk to residents in care.
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Provide proof of training with an up-to-date LIC 500 for staffing to CCL.
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: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
01/19/2024 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20240119110310

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: 4DATE:
01/29/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Isabel Lopez, SupervisorTIME COMPLETED:
12:55 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not ensure incidental medical and dental care is being provided to residents in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above. LPA met with Isabel Lopez, supervisor and explained the purpose of the visit.
LPA De Leon conducted the 10 - day complaint visit on 01/26/2024 and collect records. LPA conducted interviews with Staff on 01/22/2025 at 1:30pm, 2:30pm, and 2:45pm. LPA De Leon conducted additional staff interviews on 01/28/2025 at 1:31pm, 2:20pm, 2:57pm and 3:59pm.. LPA reviewed charting for 2024 ffor R1 and R2 at the facility today.
On the allegation: Staff do not ensure incidental medical and dental care is being provided to residents in care. LPA interviewed staff and reviewed facility records which revealed staff were reporting in charting and verbally to the lead/supervisors the residents needing medical and dental care. Appointments were made for some of the residents and some of the resident appointments were made several months out. Based on the evidence this allegation is Unsubstantiated at this time.
Exit interview conducted and copy of report printed for Supervisor.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
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 4