197607305-9-5-2024-28-AS-RORN-D99PCR-20240919111223

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607305
Report Date: 09/05/2024
Date Signed: 09/05/2024 02:18:03 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/29/2024 and conducted by Evaluator Jose Villalobos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240829135014

FACILITY NAME:	CARRILLO MANOR		FACILITY NUMBER:	197607305
ADMINISTRATOR:	ROWENA MARANTAL-CARRILLO		FACILITY TYPE:	740
ADDRESS:	14006 SYLVANWOOD AVE.		TELEPHONE:	(213) 281-1439
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY:	6	CENSUS: 4	DATE:	09/05/2024
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Administrator Rowena Carrillo		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff does not ensure resident is fed resulting in resident losing significant amount of weight.
Staff is mismanaging resident's medications.
Staff does not address changes in resident's medical conditions.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced complaint investigation visit for the allegation(s) listed above. LPA met with Administrator Rowena Carrillo and the purpose of the visit was disucuseed.

LPA conducted the following during todays visit: LPA interviewed residents #1-#4 (R1-R4), interviewed staff #1-#3 (S1-S3), interviewed home health agency nurse (N1), and interviewed R1's responsible party (F1). LPA also reviewed R1's medications as well as their medication list. LPA reviewed and collected copies of R1s facesheet, physicians reports, appraisal, and medication list.

The investigation revealed the following:
In regards to the allegation "Staff does not ensure resident is fed resulting in resident losing significant amount of weight" it is alleged that the resident is not being provided meals as they have lost a lot of weight in the recent months....
Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240829135014

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CARRILLO MANOR	FACILITY NUMBER: 197607305
	VISIT DATE: 09/05/2024

NARRATIVE

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(3) of (3) Staff interviewed denied the allegation. (4) of (4) Residents could not corroborate the allegation. R1 stated they are provided meals and there are days where they do not want to eat the food. Interviews with staff, F1 and N1 added that R1 is provided meals but there are times where R1 does not have the energy to finish meals due to weakness from dialysis treatments. Interview with F1 details that this had been a gradual decline in weight that started prior to being admitted to the facility. All persons interviewed stated that the staff do provide meals to residents in care. Based on interviews, observations and file review, there was not enough supportive evidence to concur with the reported allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

In regards to the allegation "Staff is mismanaging resident's medications" it is alleged that R1 is not receiving all of their prescribed blood pressure medications. It was alleged that there should be three (3) different blood pressure medications on file for R1; however, the facility only has one (1). (3) of (3) Staff interviewed denied the allegation. (4) of (4) Residents interviewed could not corroborate the allegation. Interview with staff and F1 state that there have been no medication changes for R1 since they arrived at the facility. They stated the medication list on file to be accurate and up to date on the prescribed medications for R1. N1 also confirmed that they have not observed any medications issues for R1 in the facility. LPA reviewed R1's medication list and matched the list with all medications on hand in the facility. LPA did not observe any medication errors or any prescription orders not being filled. LPA was not provided with proof of medications that should have been provided to R1 other than what was on file. Based on interviews, observations and file review, there was not enough supportive evidence to concur with the reported allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

In regards to the allegation "Staff does not address changes in resident's medical conditions." it is alleged that R1 has changes in their cognitive function not being addressed by the facility. (3) of (3) Staff interviewed denied the allegation. (4) of (4) Residents interviewed could not corroborate the allegation. R1 moved into the facility on 6/29/24. Physicians report on file is dated 6/26/24. This physicians report along with the pre-appraisal completed show that R1 does have an record of a medical condition affecting their cognitive function. Interviews with staff as well as F1 show that there have been no changes in R1s cognitive function that are different from when they first were admitted to the facility. This means there has been no need to address changes as their has not been any. Based on interviews, observations and file review, there was not enough supportive evidence to concur with the reported allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit Interview conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

LIC9099 (FAS) - (06/04)

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