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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320160
Report Date: 11/13/2024
Date Signed: 11/13/2024 08:30:54 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/07/2024 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20241107125841
FACILITY NAME:CARRIAGE CREST HOMECARE IIFACILITY NUMBER:
198320160
ADMINISTRATOR:RODERICK, TOMFACILITY TYPE:
735
ADDRESS:23124 CAROLDALE AVENUETELEPHONE:
(424) 477-5112
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY:4CENSUS: 4DATE:
11/13/2024
UNANNOUNCEDTIME BEGAN:
08:52 AM
MET WITH:Eboney JonesTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Staff do not treat residents with dignity and respect.
INVESTIGATION FINDINGS:
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On 11/13/24, California Department of Social Services/Community Care Licensing (CDSS/CCL) associate conducted an initial unannounced complaint visit. (CDSS/CCL) associate was greeted by Administrator Ebony Jones. (CDSS/CCL) associate explained the purpose of this visit was to investigate the allegation mentioned above.

The investigation consisted of the following: A tour of the physical plant, interviews, and collection of records. Interviews with staff #1-#2 (S1-S2), clients #1-#4 (C1-C4) and witness #1-#2 (W1-W2). A review of Personnel Report LIC 500 dated: 11/13/24), Registered of Faciltiy Clients LIC 9020 (dated: 03/01/22) staff training materials, Face Sheet, Physicians Report (dated: 08/08/24), Physician’s Orders (dated: 11/01/24), Appraisal/Needs Service Plan LIC 625 (dated: 07/01/24) Quarterly Report (dated: 07/18/24), Incident Report LIC 624 (dated: 11/07/24) and Medication Administration Record (MAR) (dated: 11/01/24). A collateral visit conducted at Moneta Learning Center on 11/13/24.
(Evaluation Report continues LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
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 3
Control Number 11-AS-20241107125841
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: CARRIAGE CREST HOMECARE II
FACILITY NUMBER: 198320160
VISIT DATE: 11/13/2024
NARRATIVE
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Family Representative (W2) to (C1), had kind words of the staff and that care and supervision services provided at this home were acceptable. (W2) claimed to be uncertain if this accusation has some merit. (W2) communicated that (C1) has had a difficult time with changes in health condition, modification of medications, and modification of group home environment could account for (C1’s) way of expressing painful emotions.

As a result of the Department reviewing client # (C1’s) Face Sheet, Physicians Report (dated: 08/08/24), Physician’s Orders (dated: 11/01/24), Appraisal/Needs Service Plan LIC 625 (dated: 07/01/24) Quarterly Report (dated: 07/18/24), Incident Report LIC 624 (dated: 11/07/24) and Medication Administration Record (MAR) (dated: 11/01/24) revealed (C1) is on (14) prescribed medications. Eleven (11) out of fourteen (14) present mental condition side effects such as depression, confusion, anxiety, headache, and dizziness (ref. NIH.com). Based on the information gathered, there is no sufficient evidence to support the allegation mentioned in this complaint.



Based on the information collected, an inspection of the facility, observation and interviews conducted, and an analysis of records reviewed, the Department found no evidence to support the allegation mentioned in this complaint. 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.

An exit interview is conducted with Administrator Eboney Jones, and a copy of the report is provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 11-AS-20241107125841
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: CARRIAGE CREST HOMECARE II
FACILITY NUMBER: 198320160
VISIT DATE: 11/13/2024
NARRATIVE
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INVESTIATION REVEALED THE FOLLOWING:

ALLEGATION: Staff do not treat residents with dignity and respect.

The details of this complaint alleged that staff do not treat client #1 (C1) with dignity and respect. It is reported that staff #1 (S1) often says unkind things directed at (C1). No further information was provided on this matter or specific details regarding what was said to (C1).

On 11/13/24, between 9:45am – 2:17 pm, the Department interviewed (3) out of (4) clients who could not corroborate this accusation. Clients #3-#4 (C3-C4) claimed the staff treated them with respect and dignity and stated they have not experienced or observed any mistreatment from staff. (C1) was complimentary of all staff and (C1) also claimed to have been treated with respect. (C1) did mention staff #1 (S1) who made a derogatory comment a few weeks back. (C1) indicated that (C1) was uncertain if the comment was serious or it was a joke. Nevertheless, (C1) stated it only happened that one time and there were no other witnesses who overheard the comment. (C1) claimed that all are terms with (S1). (C2) was interviewed but unable to hold a conversation as a result of (C2's) disability.

On 11/13/24, between 10:50 am - 11:55 am, the Department interviewed (2) out of (2) who claimed this accusation is false. Staff #1 (S1) denied ever making any derogatory comments directed at (C1) and said this accusation is untrue. (S1) specified working the night shift from 9 pm – 5 am and that interactions with (C1) are limited. (S1) reported by the time (S1) starts the evening shift, (C1) majority of the time is asleep throughout the evening. (S1) expressed that (C1) values the clients and the job. (S1) asserted that her purpose of a Direct Support Provider (DSP) is to ensure the health and safety of the clients. (S2) claimed when immediately was made aware of the matter involving (C1) and (S1), (S2) conducted an internal investigation that included interviews with day program staff, facility staff, family representative, and clients at the group home. (S2) reported that (C1) could not provide an exact time or date, nor could explain exactly what happened. (S2) reported the matter to Harbor Regional Center representatives, and a meeting was held on 11/8/24. (C1) was present at this meeting and communicated to be pleased living at the group home and that (C1) was treated by staff with regard.

On 11/13/24, between 09:50 am - 11:50 am, the Department interviewed (2) out of (2) witnesses who were unable to support this allegation. Executive Director (W1) stated (C1) has not voiced concerns to any staff at the day program about any staff working at the group home. Evaluation Report continues LIC 9099-C) This report serves as an amendment to clarify finding on lines 14, 15 & 20. It does not supersedes the complaint investigation findings reflected on report created on 11/13/24.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3