197607558-5-4-2022-28-AS-SCOL-CERSTF-20220525140929

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607558
Report Date: 05/04/2022
Date Signed: 05/04/2022 11:48:48 AM

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
04/29/2022 and conducted by Evaluator David Sicairos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220429133440

FACILITY NAME:	CARTER PLACE, THE		FACILITY NUMBER:	197607558
ADMINISTRATOR:	ARGIRI BRATAKOS		FACILITY TYPE:	740
ADDRESS:	400 W. CARTER AVE.		TELEPHONE:	(626) 374-4920
CITY:	SIERRA MADRE	STATE: CA	ZIP CODE:	91024
CAPACITY:	6	CENSUS: 4	DATE:	05/04/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Crystal Galvan; Administrator		TIME COMPLETED:	12:03 PM

ALLEGATION(S):

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Facility staff does not safeguard resident's private information.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Sicairos conducted an unannounced complaint visit regarding the above stated allegation. LPA met with Administrator Crystal Galvan and explained the reason for the visit.

The investigation consisted of the following: LPA obtained copies of Staff and Resident Rosters. LPA toured the facility and interviewed the Administrator, Staff #1 - Staff #2. LPA attempted to interview Resident #1 - Resident #4, but due to residents cognitive impairment was unable to obtain any relevant information.

The investigation revealed the following: in regards to the allegation "facility staff does not safeguard resident's private information", it is alleged that documents containing residents personal information are not being properly discarded by the facility. Administrator indicated documents containing residents private information are centrally stored in her office or locked in the medication cabinet. Any paperwork that is discarded is torn or shredded prior to being placed in the trash.

(CONTINUED ON 9099C)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: David Sicairos
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

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-20220429133440

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: CARTER PLACE, THE	FACILITY NUMBER: 197607558
	VISIT DATE: 05/04/2022

NARRATIVE

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Administrator also indicated that due to the location of the home being in close proximity to the mountains, there have been instances in the past were animals have gone through the trash cans and have scattered the trash. Staff members interviewed indicated they were not aware of the allegation. Staff members interviewed indicated paperwork containing confidential information is centrally stored and discarded by the Administrator. During today's visit, LPA toured the facility and surrounding areas outside the facility and did not observe any discarded paperwork containing confidential information. Therefore there was insufficient evidence to corroborate with this allegation.

Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: David Sicairos
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

LIC9099 (FAS) - (06/04)

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