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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206911
Report Date: 01/04/2023
Date Signed: 01/05/2023 02:15:10 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
10/10/2022 and conducted by Evaluator Mai Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20221010082850
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: 3DATE:
01/04/2023
UNANNOUNCEDTIME BEGAN:
10:26 AM
MET WITH:Administrator Katherine "Katie" Chattom via telephone and Licensed Vocation Nurse Kimberly Pendergraft, TIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Residents sustained injuries while in care.
Staff did not schedule resident's medical appointments in a timely manner.
INVESTIGATION FINDINGS:
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On 01/04/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to deliver complaint findings on the above allegations. LPA introduced self, stated the purpose of the visit, and met with Kimberly Pendergraft, Licensed Vocational Nurse (LVN) Administrator Katherine “Katie” Chattom and Program Director Misty Bryson was called and unable to attend meeting. Administrator authorized LVN to received and signed report. LPA spoke with Administrator via telephone and delivered complaint findings.

During the course of the investigation record were reviewed and interviews were conducted. C1 and C2 sustained injuries while in care. Staff unaware how client’s sustained injuries. C1 and C2 was scheduled for medical appointment after Regional Center observed client’s with injuries.

Based on record reviewed and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are 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 via email to Administrator.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023
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 24-AS-20221010082850
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: 01/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/05/2023
Section Cited
CCR
80065(f)(3)
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All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. 3) Provision of client care and supervision, including communication.

This requirement was not met:
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Licensee will submit a plan of correction detailing the steps of how staff will complete documentations of injuries observed and occurred and body checks to Fresno CCL by the 1/4/23.
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Based on records reviewed and interviews conducted, C1 and C2 sustain injuries while in care. Clients' injuries were sustained, and cause was unknown which possess an immediately health and safety and personal rights risk to the client in care.
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Licensee shall have in-service training for documentation of injuries being observed and on body checks. Documents of staff in-service training including rooster of attendance shall be submitted to CCL by 1/10/23.
Type B
01/10/2023
Section Cited
CCR
85075.4(a)
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Observation of the Client (a)The licensee shall regularly observe each client for changes in physical, mental, emotional and social functioning.

This requirement was not met:
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Licensee will submit a plan of correction detailing the steps of how staff will seek medical attention when client’s are observed with injuries. POC shall be submitted to Fresno CCL by the 1/10/23.
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Based on records reviewed and interviews conducted, clients' medical appointment was not scheduled for C1 and C2 for injuires until after Regional Center observed and reported to facility management. This possess a potential health and safety and personal rights risk to the client in care.
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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: 01/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2