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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206911
Report Date: 10/17/2022
Date Signed: 10/17/2022 01:54:07 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, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/13/2022 and conducted by Evaluator Mai Yang
COMPLAINT CONTROL NUMBER: 24-AS-20220913104947
FACILITY NAME:CAROLINA HOMEFACILITY NUMBER:
107206911
ADMINISTRATOR:DAMON HILLFACILITY TYPE:
735
ADDRESS:1086 CAROLINA AVENUETELEPHONE:
(559) 326-7758
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:4CENSUS: 4DATE:
10/17/2022
UNANNOUNCEDTIME BEGAN:
08:52 AM
MET WITH: Area Director Katherine Chattom and Program Director Misty BrysonTIME COMPLETED:
01:38 PM
ALLEGATION(S):
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Facility is not reporting incidents to the CCL office
Resident was not accorded dignity in his/her personal relationships with staff and other persons
INVESTIGATION FINDINGS:
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On 10/17/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct subsequent complaint investigation visit and deliver complaint findings on the above allegations. LPA introduced self, stated the purpose of the visit, and met with Misty Bryson, Program Director. Katherine Chattom, Area Director arrived shortly.

During the course of the investigation records were reviewed and interviews were conducted. The facility failed to report written reports of incidents to the department. Based on interviews, on 09/13/22, S1 called the Area Director, Katherine Chattom via facetime video, to show her that S2 had not changed C1’s brief and in doing so, pulled C1’s pants down which relieved that C1 was not soiled. The facetimie video chat was a violation of C1’s personal rights. Based on record reviewed and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Under California Code of Regulations, Title 22, are being cited on the attached LIC 9099D. Plan of correction was discussed. An exit interview was conducted, and a copy of this report and appeal rights was provided to the Area Director.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/13/2022 and conducted by Evaluator Mai Yang
COMPLAINT CONTROL NUMBER: 24-AS-20220913104947

FACILITY NAME:CAROLINA HOMEFACILITY NUMBER:
107206911
ADMINISTRATOR:DAMON HILLFACILITY TYPE:
735
ADDRESS:1086 CAROLINA AVENUETELEPHONE:
(559) 326-7758
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:4CENSUS: 4DATE:
10/17/2022
UNANNOUNCEDTIME BEGAN:
08:52 AM
MET WITH: Area Director Katherine Chattom and Program Director Misty BrysonTIME COMPLETED:
01:38 PM
ALLEGATION(S):
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9
Resident received unexplained bruising due to multiple falls
INVESTIGATION FINDINGS:
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On 10/17/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct subsequent complaint investigation visit and deliver complaint finding on the above allegation. LPA introduced self, stated the purpose of the visit, and met with Misty Bryson, Program Director. Katherine Chattom, Area Director arrived shortly.

During the course of the investigation, the Department conducted interviews and records were reviewed. Record shows that client did have some falls that was reported to the department. Based on the interviews and records reviewed there was insufficient evidence to prove or disprove that the unexplained bruising was due to mutliple falls. Based on record reviewed and interviews which were conducted, the preponderance of evidence standard has not been met, therefore the above allegation is found to be UNSUBSTANTIATED. Exit interview was conducted. A copy of this report was provided to Area Director.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 24-AS-20220913104947
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: CAROLINA HOME
FACILITY NUMBER: 107206911
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/18/2022
Section Cited
CCR
80072(a)(1)
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80072 (a)(1) Personal Rights (a) Except for children’s residential facilities, each clieed dignity in his/her personal relationships with staff and other persons.

This requirement was not met as evidenced by:
nt shall have personal rights…(1)To be accord
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Licensee will submit a plan of correction detailing the step the facility shall take to ensure the Personal Right Regulation are met by the due date.
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Based on interviews conducted, S1 called the Area Director, Katherine Chattom via facetime video, to show her that S2 had not changed C1’s brief and by doing so, pulled C1’s pants down which relieved that C1 was not soiled. The facetiming video chat was a violation of C1’s personal rights which poses/posed a potential health and safety or personal rights risk to person in care.
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Licensee agreed to retrained staff on Personal rights regulation. Licensee will submit documentation of training topics and staff attendance roster to the Fresno CCL office by 10/24/22.
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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: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 24-AS-20220913104947
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: CAROLINA HOME
FACILITY NUMBER: 107206911
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2022
Section Cited
CCR
80061(b)(1)(D)
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80061 (b)(1)(D) Reporting Requirements (b)Upon the occurrence…of any of the events specified in (1) a report shall be made to the licensing agency…a written report containing the information… (2) shall be submitted to the licensing agency within seven days following the occurrence…(D)Any injury to any client which requires medical treatment.

This requirement was not met as evidenced by:
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Licensee agrees to submit a plan detailing steps the facility will take to ensure the requirements of Reporting requirements are met by the POC due date.
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Based on interviews: the licensee did not ensure a written incident report on C1 was submitted to the Fresno CCL office within seven days of incident on that occurred on 09/5/22, 09/12/22. Staff confirmed no written report was submitted to department. There was no indication that an incident report was submitted as required, , this poses a potential health and safety risk to residents in care.
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Licensee agreed to train staff on the requirements of Reporting Requirements. Documentation of training topics and attendance will be submitted to the Fresno CCL office by 10/24/22.
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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: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5