<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320037
Report Date: 07/07/2022
Date Signed: 07/07/2022 04:47:29 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, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/04/2022 and conducted by Evaluator Stephanie Cifuentes
COMPLAINT CONTROL NUMBER: 11-NP-20220204152304
FACILITY NAME:CARMIE HOME CAREFACILITY NUMBER:
198320037
ADMINISTRATOR:RECIO, PAOLOFACILITY TYPE:
735
ADDRESS:14528/30 HALLDALE AVETELEPHONE:
(310) 938-2190
CITY:GARDENASTATE: ZIP CODE:
90247
CAPACITY:9CENSUS: 7DATE:
07/07/2022
UNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:Rosauro De GuzmanTIME COMPLETED:
04:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Illegal Eviction
Facility did not get authorization from conservator for medical care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 7/7/2022, Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced subsequent complaint visit at this facility. LPA spoke with Administrator Paolo Recio via telephone prior to entering the facility to conduct risk assessment and was informed that facility has no COVID-19 cases nor do any of the clients have symptoms. LPA arrived at facility and explained the purposed of the visit is to deliver findings regarding the investigation listed above. LPA was granted entry to the facility and met with staff Rosauro de Guzman.

The investigation consisted of the following: On 2/10/2022 LPA Cifuentes conducted a tour of facility grounds. Facility consists of a living room, kitchen, dining room, 4 resident bedrooms, 1 staff bedroom, 2 bathrooms, back yard with shaded area and detached garage. LPA interviewed Staff (S1) and Clients 2-Client 7 (C2-C7). LPA reviewed facility files and requested the following documents: staff and client rosters and other documents pertinent to the investigation.
Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
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
Control Number 11-NP-20220204152304
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 DR #100
MONTERY PARK, CA 91754
FACILITY NAME: CARMIE HOME CARE
FACILITY NUMBER: 198320037
VISIT DATE: 07/07/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
INVESTIGATION REVEALED THE FOLLOWING:
Allegation: Illegal Eviction

The complainant alleges that client was released from hospital and facility would not allow them to return. LPA interviewed administrator Paolo Recio, who stated he spoke with C1’s doctor and was instructed to take C1 to Mission Hospital for an assessment, as client had been falling frequently and facility staff was worried about their stbility. C1’s belongings remained in the home and Mr. Recio was not evicting C1, he was waiting for a medical assessment to see if the facility would still be able to meet C1’s needs. LPA Cifuentes spoke with social services staff at Mission Hospital who stated per their records, it was noted by ER nurse that C1 was in ER on 1/6/2022 and discharged to Carmie Care Home, then later returned to ER same day because facility stated they did not have a bed for C1. LPA reviewed facility files and noted that discharge paperwork was received for C1 on 1/4/2022 for So Cal Hospital of Hollywood. LPA Cifuentes interviewed clients (C2-C7) regarding the allegation. Of those interviewed, 6 out of 6 stated they had not been illegally evicted by facility staff, with one noting that C1 had left for medical reasons and they kept falling. LPA interviewed staff (S1) regarding the allegation. Of those interviewed 1 out of 1 stated facility had not illegally evicted any clients. Based on information gathered, the department found sufficient evidence to support the allegation.

Allegation: Facility did not get authorization from conservator for medical care.

The complainant alleges that facility staff took client to hospital without informing conservator. LPA interviewed administrator Paolo Recio on 2/2/2022 who stated C1 told him their legs felt week, so they contacted doctor and asked where they should take C1 to get checked. On 6/7/2022, administrator Recio stated they contacted both clients conservator and psychiatrist regarding possible hospitalization and called 911 when they noticed clients weakness. Per W1, conservator was not notified until after C1 was taken to the hospital. LPA Cifuentes interviewed clients (C2-C7) regarding the allegation. Of those interviewed, only one stated a conservator was involved with their medical appointments, the other 6 stated they handled it on their own of it was handled by their doctors. LPA interviewed staff (S1) regarding the allegation. Of those interviewed 1 out of 1 facility contacts conservators or family unless clients handle their own medical care. Based on information gathered, the department found sufficient evidence to support the allegation.

Based on LPAs observations, interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D.

An exit interview was conducted and a copy of the LIC 9099 was provided to Paolo Recio, administrator.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 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, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/04/2022 and conducted by Evaluator Stephanie Cifuentes
COMPLAINT CONTROL NUMBER: 11-NP-20220204152304

FACILITY NAME:CARMIE HOME CAREFACILITY NUMBER:
198320037
ADMINISTRATOR:RECIO, PAOLOFACILITY TYPE:
735
ADDRESS:14528/30 HALLDALE AVETELEPHONE:
(310) 938-2190
CITY:GARDENASTATE: ZIP CODE:
90247
CAPACITY:9CENSUS: 7DATE:
07/07/2022
UNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:Rosauro GuzmanTIME COMPLETED:
04:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility has not refunded resident's rent money
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 7/7/2022, Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced subsequent complaint visit at this facility. LPA spoke with Administrator Paolo Recio via telephone prior to entering the facility to conduct risk assessment and was informed that facility has no COVID-19 cases nor do any of the clients have symptoms. LPA arrived at facility and explained the purposed of the visit is to deliver findings regarding the investigation listed above. LPA was granted entry to the facility and met with staff Rosauro de Guzman.

The investigation consisted of the following: On 2/10/2022 LPA Cifuentes conducted a tour of facility grounds. Facility consists of a living room, kitchen, dining room, 4 resident bedrooms, 1 staff bedroom, 2 bathrooms, back yard with shaded area and detached garage. LPA interviewed Staff (S1) and Clients 2-Client 7 (C2-C7). LPA reviewed facility files and requested the following documents: staff and client rosters and other documents pertinent to the investigation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
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 11-NP-20220204152304
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 DR #100
MONTERY PARK, CA 91754
FACILITY NAME: CARMIE HOME CARE
FACILITY NUMBER: 198320037
VISIT DATE: 07/07/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Facility has not refunded resident's rent money

The complainant alleges that client was evicted by facility and that a refund was not issued. LPA interviewed administrator Paolo Recio, who stated that an eviction notice had not been issued for any client and only one client was out at a SNF being evaluated by their staff. Administrator Recio added that he has no issue with refunding C1’s money if they will not be returning to the facility. On 7/7/2022 Administrator Recio told LPA that a full refund was issued to C1 when family signed their discharge form. A copy of the check was provided as well as a letter signed by C1’s family stating they had received the refund was provided to LPA Cifuentes. LPA toured facility on 2/2/2022 and noted that C1’s items remained at facility. LPA reviewed facility files and found that admissions agreement for C1 had a note on the bottom dated for 4/30/2022 stating that C1’s family had agreed to pick up all C1’s belongings and sign discharge from facility. Document was signed by C1’s conservator. LPA also noted during records review that facility has no refund policy on admissions agreement. LPA Cifuentes interviewed clients (C2-C7) regarding the allegation. Of those interviewed, 6 out of 6 stated they had not needed any monies refunded from facility. LPA interviewed staff (S1) regarding the allegation. Of those interviewed, 1 out of 2 stated refunds had been issued when facility was told resident would not be returning.

Based on information gathered, the department did not find sufficient evidence to support the 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.

An exit interview was conducted and a copy of the LIC 9099 was provided to Paolo Recio, administrator.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-NP-20220204152304
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 DR #100
MONTERY PARK, CA 91754

FACILITY NAME: CARMIE HOME CARE
FACILITY NUMBER: 198320037
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/28/2022
Section Cited
CCR
80068.5(1)(4)(a)
1
2
3
4
5
6
7
Eviction Procedures
A Needs and Services Plan modification must have been performed...which determined that the client's needs cannot be met by the facility and the client has been given the opportunity to relocate as specified in Section 80068.3(b).
THis requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will review eviction procedures and will outline a plan on how he will adhere to eviction procedure and re-evaluate residents to reflect Title 22. Licensee will send document to CCLD via fax or email by POC due date
8
9
10
11
12
13
14
Through observation, on 7/7/2022 LPA observed that C1 had not been evaluated by facility and a new need and services plan created before determining that they could not return from hospital. This is a potential health and safety risk to clients in care
8
9
10
11
12
13
14
Type B
07/28/2022
Section Cited
CCR
80061(f)
1
2
3
4
5
6
7
Reporting requirements
The items specified in (b)(1)(A) through (H) above shall also be reported to the client's authorized representative, if any.
1
2
3
4
5
6
7
Licensee will review reporting requirements and will outline a plan on how they will adhere to those requirements in the future to reflect title 22. Licensee will send documents to CCLD via fax or email by POC due date.
8
9
10
11
12
13
14
Through observation and interview, LPA Cifuentes noted that facility failed to report to C1's conservator that client would be taken to hospital for treatment. LPA also noted that no unusual incident report was made to CCLD. This is a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
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: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5