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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 01:13:24 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
07/30/2024 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20240730171129
FACILITY NAME:C.A.L.L.-CARMELITA HOUSEFACILITY NUMBER:
405801701
ADMINISTRATOR:JONI CHAPMANFACILITY TYPE:
740
ADDRESS:2660 FERROCARRILTELEPHONE:
(805) 466-8502
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:6CENSUS: 4DATE:
01/29/2025
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Isabel Lopez, SupervisorTIME COMPLETED:
01:25 PM
ALLEGATION(S):
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Staff are not meeting resident's dental needs.
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 08/06/2024 toured the facility kitchen, collected records, and conducted interviews with Staff.
LPA interviewed additional staff on 01/21/2025 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.

On the allegation: Staff are not meeting resident's dental needs. LPA interviewed staff and reviewed charting and dental records for resident 1 (R1) which revealed R1 had charting notes and staff told lead/supervisors about R1’s loose teeth and bleeding, at some point the Lead/supervisor made a dentist appointment for R1 and R1 had oral surgery.
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 5
Control Number 29-AS-20240730171129
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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 R1 was not compliant with the post care for the dental surgery and ended up in the hospital for further medical care. According to interviews R1 had been visited by onsite mobile dentist arranged through Tri-counties Regional Center in the 2024 on a few occasions. Staff interviews revealed staff wash assisting R1 with normal brushing and cleaning of R1 mouth and teeth. The lack of immediate attention to R1’s loose teeth and the reports staffing made to the lead/supervisor after the dental surgery were not immediate for R1’s needed care based on R1 not being seen timely this allegation is Substantiated at this time.

Exit interview conducted, deficiency 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 5
Control Number 29-AS-20240730171129
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 A
01/31/2025
Section Cited
CCR
87465(a)(1)
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(a) plan for incidental medical and dental care shall be developed by each facility. The...:(1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by:
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Licensee agreed to review regulation 87465 and have a full understanding of when to seek medical and dental care for residents, for lead staff to know full duty statement and sign a statement of understanding of how and when to seek medical and dental care for residents
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Based on staff interviews and records review the Licensee did not comply with the regulation above, R1 had immediate dental needs that were not addressed timely by the lead/supervisor based on staff charting notes and verbal notifications which poses an immediate health, safety and personal rights risk to residents in care.
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in care as well as train all facility staff on the regulation and reporting to lead staff at the facility, send proof of training and statement of understanding to CCL.
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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: 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 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
07/30/2024 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20240730171129

FACILITY NAME:C.A.L.L.-CARMELITA HOUSEFACILITY NUMBER:
405801701
ADMINISTRATOR:JONI CHAPMANFACILITY TYPE:
740
ADDRESS:2660 FERROCARRILTELEPHONE:
(805) 466-8502
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:6CENSUS: 4DATE:
01/29/2025
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Isabel Lopez, SupervisorTIME COMPLETED:
01:25 PM
ALLEGATION(S):
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Staff did not prevent resident from becoming malnourished while in care.
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 08/06/2024 toured the facility kitchen, collected records, and conducted interviews with Staff. LPA interviewed additional staff on 01/21/2025 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.

On the allegation: Staff did not prevent resident from becoming malnourished while in care. LPA toured facility kitchen and food supply which met the regulation on food services for the amount for the resident in care. LPA interviewed staff which revealed all staff offered Resident 1 (R1) a variety of healthy foods daily, R1 was a picky eater, R1 would not eat what R1 did not like or did not want,
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 5
Control Number 29-AS-20240730171129
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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Staff would give several options of food and meals to R1, R1 would throw food R1 did not want to eat and would only eat what R1 wanted to eat. R1 ate cereal, yogurt and ensure drinks if R1 liked the flavor given. R1 did not like healthy food options given and would always eat the same things. R1 has a right to eat what R1 wanted but staff always offered several choices to R1. The facility had a menu they followed for meals to residents and always had additional choices if the resident did not like what was on the menu. Based on the evidence this allegation is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report 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: 5 of 5