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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320037
Report Date: 08/31/2023
Date Signed: 08/31/2023 03:54:50 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/22/2023 and conducted by Evaluator Felisa Shirley
COMPLAINT CONTROL NUMBER: 11-AS-20230822165302
FACILITY NAME:CARMIE HOME CAREFACILITY NUMBER:
198320037
ADMINISTRATOR:RECIO, PAOLOFACILITY TYPE:
735
ADDRESS:14528/30 HALLDALE AVETELEPHONE:
(310) 938-2190
CITY:GARDENASTATE: CAZIP CODE:
90247
CAPACITY:9CENSUS: 7DATE:
08/31/2023
UNANNOUNCEDTIME BEGAN:
08:43 AM
MET WITH:Rosauro De GuzmanTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff do not assist residents with transportation to medical appointments
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced complaint visit on 8/31/23. LPA Shirley spoke with Administrator Paolo Recio via telephone and met with staff Rosauro de Guzman, Caregiver. LPA Shirley explained the purpose of today's visit and was granted entry.


The investigation consisted of the following: Interviews were conducted with staff 1-2 (S1-S2) and residents R1-R6. LPA requested and received the following: Staff and Resident rosters, Admission agreements, and facility files.




Con'd 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
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 4
Control Number 11-AS-20230822165302
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CARMIE HOME CARE
FACILITY NUMBER: 198320037
VISIT DATE: 08/31/2023
NARRATIVE
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Allegation: Staff do not assist residents with transportation to medical appointments.

Investigation revealed the following: Interviews were conducted with staff 1-2 (S1-S2), and residents 1-6 (R1-R6). LPA asked all residents, “Do you receive help with transportation when you need it?”, 5 out of 6 residents stated, “Yes”, Administrator does assist in transportation needs. LPA noted that Administrator, Paolo Recio, S1 stated he offers to take residents to appointments if requested and if they have issues with Access or family and friends. LPA noted that 5 out of 6 residents stated that a family member or friend assist with transportation needs.

From 9:10am to 11am, LPA reviewed facility records, Per Carmie Care’s Admission Agreement, in the section, “Transportation for Private Pay Clients”, states that, “Basic transportation to and from medical and dental appointments is included within a radius of ten (10) miles on designated days, (Tuesdays and Thursdays)”. Admission Agreement also states, there is no charge for SSI recipients under any circumstances.

Based on interviews there is insufficient evidence to support the allegation: Staff do not assist residents with transportation to medical appointments. 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.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/22/2023 and conducted by Evaluator Felisa Shirley
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230822165302

FACILITY NAME:CARMIE HOME CAREFACILITY NUMBER:
198320037
ADMINISTRATOR:RECIO, PAOLOFACILITY TYPE:
735
ADDRESS:14528/30 HALLDALE AVETELEPHONE:
(310) 938-2190
CITY:GARDENASTATE: CAZIP CODE:
90247
CAPACITY:9CENSUS: DATE:
08/31/2023
UNANNOUNCEDTIME BEGAN:
08:43 AM
MET WITH:Rosauro De GuzmanTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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 Facility is malodorous.
INVESTIGATION FINDINGS:
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Report has been amended to clarify allegation. It does not change the findings delivered on 8/31/2023.
Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced complaint visit on 8/31/23. LPA Shirley spoke with Administrator Paolo Recio via telephone and met with staff Rosauro de Guzman, Caregiver. LPA Shirley explained the purpose of today's visit and was granted entry.
The investigation consisted of the following: Interviews were conducted with staff 1-2 (S1-S2) and residents R1-R6. LPA requested and received the following: Staff and Resident rosters, Admission agreements, and facility files.
Investigation revealed the following: Interviews were conducted with staff 1-2 (S1-S2), and residents 1-6 (R1-R6), LPA ask all residents, “Do you believe that there is a bad smell within this facility?”, 5 out 6 residents stated that yes there is a noticeable smell in the facility.
S1 stated that yes there are issues with two (2) residents. R3 is afraid to go into the bathroom so she does not shower. Administrator is working with her to resolve the problem. R7 has an incontinence problem. Administrator stated that he is working with resident’s doctors to find out what the issue is.
Per LPA’s notes and observation, there is an unpleasant order upon entrance to the facility. LPA took a tour of the facility and observed room #3 and this room is malodorous as well.
Based on LPAs observations and interviews which were conducted, 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 6 are being cited on the attached LIC 9099D.
Exit interview conducted and copy of report was given.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 11-AS-20230822165302
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CARMIE HOME CARE
FACILITY NUMBER: 198320037
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/14/2023
Section Cited
HSC
80087(a)
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80087 Buildings and Grounds
(a) The facility shall be clean, safe,sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:






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Administrator shall review regulation and come up with a plan to assist the residents in care, in order to achieve a clean and safe facility free of ordors. Administrator will clean room #3 by POC due date of 9/14/23. Administrator was general clean the facility. Administrator will work with resident R3 to shower. Administrator will work with doctors with incontinence for resident R-7
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Based on interview, observation, and record review, the licensee did not ensure that the facility be kept clean, safe and free of odors. At 8:43am upon entrance, facility was malordorous. LPA toured facility and room #3 was malordorous as well.

This posses a potential health risk to residents 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: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4