198320038-11-30-2021-11-AS-EMAZ-C9X3EW-20211221171150

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320038
Report Date: 11/30/2021
Date Signed: 11/30/2021 03:34:31 PM

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
11/22/2021 and conducted by Evaluator Stephanie Cifuentes

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20211122100000

FACILITY NAME:	CARMIE HOME CARE II		FACILITY NUMBER:	198320038
ADMINISTRATOR:	RECIO, ANGELO		FACILITY TYPE:	740
ADDRESS:	14532/34 HALLDALE AVE		TELEPHONE:	(424) 292-3136
CITY:	GARDENA	STATE: CA	ZIP CODE:	90247
CAPACITY:	6	CENSUS: 5	DATE:	11/30/2021
		UNANNOUNCED	TIME BEGAN:	09:13 AM
MET WITH:	Angelo Recio		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Facility is not following COVID-19 guidelines.
Facility is not maintained clean and organized.
Stacked boxes were blocking the walkway at the facility.
Facility is malodorous.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced complaint investigation at above facility. LPA arrived at the facility and was greeted by staff. LPA explained purpose of visit was to deliver findings for the allegations listed above and was allowed entry to the facility to meet with Administrator Stephanie Brown.

The investigation consisted of the following: On 11/30/2021 LPA Cifuentes met with Administrator, completed a walkthrough of facility and interviewed Resident 1 – resident 5 (R1-R5) as well as Staff 1 and Staff 2 (S1, S2). LPA also reviewed facility files and requested copies of register of facility residents, staff schedule and other documents in association with the allegations.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021

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 6

Control Number 11-AS-20211122100000

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 II	FACILITY NUMBER: 198320038
	VISIT DATE: 11/30/2021

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:
Allegation:Facility is not following COVID-19 guidelines.
It is alleged by reporting party, that during a visit to the facility, they were not screened for Covid-19 as neither thermometer or log book were available. LPA Cifuentes arrived at facility and was led to dining room table, where thermometer and sign in log were stored. LPA also saw gloves, sanitizer and wipes on the table. Staff took LPA’s temperature and had LPA fill out log book when temperature screening was completed. LPA spoke to facility Administrator Angelo Recio, who stated that facility staff lets visitors in one at a time, takes their temperature and has them fill out the log. LPA was also told that residents recently received Covid-19 booster shot. LPA spoke to residents R1-R5. R5 did not understand questions asked by LPA. LPA asked residents if visitors were screened when they came in. Out of the residents able to answer 4 out of 4 answered that they did not know if facility screened visitors and one added that no one visited. LPA Cifuentes interviewed S1 and S2 regarding allegations. When asked if the facility was screening visitor, 2 out of 2 answered that visitors were screened, and temperatures were taken by staff. out of five answered yes. Based on information gathered and service records reviewed, the Department did not find sufficient evidence to support the allegation mentioned above.

Allegation: Facility is not maintained clean and organized.
It is alleged that by reporting party that Facility that facility dining room table is cluttered with scattered paper, mail, and dishes on top of the dining room table, food and grease were found splattered on the stove, kitchen counter and several dishes as well. They also added that bathroom floor was not mopped and had a urine/sewage smell. LPA Cifuentes inspected facility upon arrival and did not find anything scattered on the table, nor any food, dishes or grease on kitchen counter or stove. LPA also inspected rooms and bathrooms and did not find any messes, dirt nor did they appear as if they had not been mopped. LPA Cifuentes spoke with Administrator Angelo Recio, who stated staff cleaned throughout the day. LPA asked facility residents if the facility is clean and organized. R5 did not understand the questions asked by LPA. LPA asked those who understood whether they felt the facility was clean, 4 out of 4 stated they believed the facility was clean, with a few adding that staff cleaned every day or every other day. LPA Cifuentes spoke with facility staff, of the two questioned, both stated they cleaned every day. Based on information gathered, the Department did not find sufficient evidence to support the allegation mentioned above.

Continued on 9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 11-AS-20211122100000

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 II	FACILITY NUMBER: 198320038
	VISIT DATE: 11/30/2021

NARRATIVE

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Allegation: Stacked boxes were blocking the walkway at the facility.
Complainant alleges that stacked boxes were blocking the walkway in the dining and living area. LPA Cifuentes toured facility and found no boxes stacked in dining and living area, nor blocking any walkways or doorways in facility. LPA spoke the Angelo Recio, administrator, who stated that one of the residents receives several boxes of diapers. When they are delivered to facility, staff immediately bring them into the living room to prevent theft and from there they ae put away. LPA interviewed residents regarding allegation. R5 did not understand question, but of the 4 residents who did, all four stated nothing blocked doorways or walkways of facility, LPA interviewed Staff 1 and 2 regarding allegations. Both staff stated they did not block doors or walkways. Based on information gathered, the Department did not find sufficient evidence to support the allegation mentioned above.

Allegation: Facility is malodorous.
Reporting party alleges that facility has a strong urine smell coming from bedrooms, restroom and hallways. LPA Cifuentes toured facility grounds and did not smell urine in any of the bedrooms, bathrooms or hallways. During interview Administrator Angelo Recio mentioned he is at facility several times and has not smelled anything except when adult briefs are being changed. LPA residents regarding allegation, and four out of four stated facility did not smell, with resident 5 not answering the question when asked. LPA interviewed staff regarding any odors in the facility and both staff stated facility does not smell, adding that they check diapers and clean. Based on information gathered, the Department did not find sufficient evidence to support the allegation mentioned above.
Continued on 9099-C

The Department’s investigation consisted of an inspection of the facility, observation, analysis of residents records, incident report, and interviews conducted and found no evidence to support the allegations: “Facility is not following COVID-19 guidelines,” “Facility is not maintained clean and organized,” “Stacked boxes were blocking the walkway at the facility,” “Facility has pests,” “Dangerous items were not locked at the facility,”
“Facility is malodorous.” 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 allegations are Unsubstantiated.

Exit interview conducted, and a copy of the report was given to Angelo Recio, Administrator.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 6

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
11/22/2021 and conducted by Evaluator Stephanie Cifuentes

COMPLAINT CONTROL NUMBER: 11-AS-20211122100000

FACILITY NAME:	CARMIE HOME CARE II		FACILITY NUMBER:	198320038
ADMINISTRATOR:	RECIO, ANGELO		FACILITY TYPE:	740
ADDRESS:	14532/34 HALLDALE AVE		TELEPHONE:	(424) 292-3136
CITY:	GARDENA	STATE: CA	ZIP CODE:	90247
CAPACITY:	6	CENSUS: 5	DATE:	11/30/2021
		UNANNOUNCED	TIME BEGAN:	09:13 AM
MET WITH:	Angelo Recio		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Dangerous items were not locked at the facility.
Facility has pests.

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021

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 6

Control Number 11-AS-20211122100000

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 II	FACILITY NUMBER: 198320038
	VISIT DATE: 11/30/2021

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Dangerous items were not locked at the facility.
It is alleged that sharps and toxins were stored in a cabinet or drawer but were not locked. LPA Cifuentes toured facility grounds and at 10:15am found a drawer in kitchen with knives which was unlocked. At 10:37am LPA found a spray bottle of cleaning solution in residents bathroom cupboard, which does not have a lock. LPA Cifuentes spoke to administrator Angelo Recio regarding allegation. Mr. Recio stated sharps and toxins should stay in locked drawer or cabinet. LPA asked facility residents if facility locked knives and toxins. Resident 5 was unable to answer questions, but of the four who could, two answered yes and the other two answered no. LPA Cifuentes spoke with facility staff about locking toxins and sharps. Both stated toxins and sharps were kept in locked drawers or cabinets. Based on information gathered, the department did find sufficient evidence to support allegation " Dangerous items were not locked at the facility.”
Based on interviews conducted and tour of facility grounds records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

Allegation: Facility has pests.
It is alleged by reporting party that there are roaches in kitchen cabinets. LPA toured facility upon arrival and did not find any pests. LPA Checked kitchen cabinets at 2:40PM and found a live cockroach under kitchen sink. LPA spoke to Administrator Angelo Recio regarding allegation. Per administrator Recio, he found some kind of droppings behind the TV several months ago. He immediately called an exterminator service and has not found any since LPA interviewed residents regarding allegation. R5 did not understand question, but of the 4 residents who did, all four stated they had not seen cockroaches in the facility. LPA interviewed Staff 1 and 2 regarding allegations. Staff one stated they had seen no cockroaches in the facility. Staff 2 stated they had seen some in the kitchen last month, but they had sprayed and had not seen any since. Based on interviews conducted and tour of facility grounds records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

An exit interview was conducted and a copy of the LIC 9099 and appeal rights forms were provided to administrator Paolo Recio.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 11-AS-20211122100000

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 II	FACILITY NUMBER: 198320038
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/30/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/01/2021 Section Cited CCR 87705(f)(1)(2)	1 2 3 4 5 6 7	The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s)...toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Staff locked the knife drawer and stored the cleaning solution outside in the laundry area. Facility will buy a lock for cabinet to store toxins and submit to CCLD via fax by POC due date.
	8 9 10 11 12 13 14	At 10:15am LPA Cifuentes found a drawer in kitchen with knives which was unlocked and at 10:37am LPA found a spray bottle of cleaning solution in residents bathroom cupboard, which does not have a lock. This poses an immediate health and safety risk to the residents in care.	8 9 10 11 12 13 14
Type B 12/15/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Adminstrator will have exterminator service come in to handle cockroachs and submit proof of completion to LPA by POC due date via fax.
	8 9 10 11 12 13 14	At 2:40PM LPA Cifuentes found a live cockroach under the kitchen sink. This poses 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.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021

LIC9099 (FAS) - (06/04)

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