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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 02:07:16 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
01/17/2025 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20250117160843
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:
02:15 PM
ALLEGATION(S):
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Staff did not get timely medical care for resident
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 01/21/2025 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: Staff did not get timely medical care for resident
LPA interview staff and resident charting records which revealed staff informed the lead/supervisor that resident 1 (R1) was having discharge and odor regularly. Charting notes have staff charting that R1 was having discharge and odor in 2024. R1 had a recent visit to CHC doctor on 01/15/2025 at 3:30pm which revealed R1 was prescribed antibiotics. Based on the evidence R1 did not receive timely medical care therefore the allegation is Substantiated at this time.

Exit interview conducted, deficiency cited, copy of report and appeal rights printed for Supervisor.
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 2
Control Number 29-AS-20250117160843
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
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 R1 was having discharge and odor in 2024 but R1 was not taken to see a doctor till 2025 which poses an immediate health, safety, and personal rights risk to residents in care.
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 and provide proof of training with an up to date LIC 500 for staffing 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: 2 of 2