<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405801701
Report Date: 01/29/2025
Date Signed: 01/29/2025 01:46:27 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
01/13/2025 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20250113160511
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:
11:00 AM
MET WITH:Isabel Lopez, AdministratorTIME COMPLETED:
01:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not provide resident medical records to emergency personnel
Licensee does not ensure staff are adequately trained to provide care for residents
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 01/21/2025 collected records and conducted interviews with Staff 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: Facility staff did not provide resident medical records to emergency personnel. LPA conducted interviews with staff that revealed staff working could not find the records the 911 EMT was requesting. The staff were able to retrieve and provide a few of the records. LPA reviewed the records at the facility and the records were not organized and most of the 2024-year records were not located. LPA was not able to locate some of the resident records required for emergency purposes. The facility recently put a staff in charge to clean up the records and filing at the facility. Based on the evidence the allegation is Substantiated at this time. 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-20250113160511
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
On the allegation: Licensee does not ensure staff are adequately trained to provide care for residents. LPA conducted interviews with staff and reviewed training records which revealed most staff felt they were trained although some felt hands on and 1 on 1 care of residents at the facility could be better. Training records revealed the facility has done more training in 2024 but not all staff did not take the required initial or annual training requirements. According to Tri- Counties Regional Center Quality Assurance the C.A.L.L. Program is not in compliance with keeping better track of all training's, data collection and charting notes. Based on the evidence the 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 5
Control Number 29-AS-20250113160511
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
HSC
1569.695(e)(1-4)
1
2
3
4
5
6
7
(e)...:(1) A resident roster with the date of birth for each resident.(2) An ANS plan for each resident.(3) A resident medication list for residents with centrally stored medications.(4) Contact information for the responsible party and physician for each resident. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee agreed to review the facility emergency disaster plan LIC. 610E, health & safety code 1569.695, make sure facility is meeting this requirement with all records and supplies necessary and train all staff at the facility on the plan/code and provide proof of training with an up to date LIC. 500 to CCL.
8
9
10
11
12
13
14
Based on interviews and record review the Licensee did not comply with the regulation above, staff were unable to locate the records for Resident to provide the EMT’s on a 911 call, which poses an immediate health, safety and personal rights risk to residents in care.
8
9
10
11
12
13
14
Type B
02/05/2025
Section Cited
CCR
87411(c)
1
2
3
4
5
6
7
(c)All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee agreed to arrange all staff to take and met the required initial and annual training requirements for CCL and provide proof of each staff meeting the training requirements as well as an updated LIC 500.
8
9
10
11
12
13
14
Based on record review the Licensee did not comply with the regulation above staff were not properly training meeting all initial and annual training requirement which poses a potential health, safety, and personal rights risk to residents in care.
8
9
10
11
12
13
14
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
01/13/2025 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20250113160511

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:
11:00 AM
MET WITH:Isabel Lopez, AdministratorTIME COMPLETED:
01:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident developed pressure injuries while 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 01/21/2025 collected records and conducted interviews with Staff 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: Resident developed pressure injuries while in care. LPA interviewed staff which revealed resident 1 (R1) had developed red areas on R1’s skin from sleeping and lying in bed often, R1 was turned and repositioned frequently while in bed and given pillows for less skin-on-skin contact. The pressure injuries were not staged and R1 did not have any open wounds. The facility provided first aid and helped assist R1 with regular cleaning and showers.
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-20250113160511
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 R1 was sent out to the hospital on a 911 call, was admitted to the hospital and discharged to a skilled nursing facility. R1 wounds were staged at a healing 2 when R1 was discharged back to the facility. According to medical records and interviews R1 never had stage 3 or 4 pressure injuries which is a prohibited health condition in CCL facilities. Based on the lack of 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