198603108-9-8-2021-11-AS-MVAO-C73QZ7-20210921123617

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603108
Report Date: 09/08/2021
Date Signed: 09/08/2021 05:14:46 PM

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 DR #100
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/07/2021 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210907161509

FACILITY NAME:	CARRIAGE CREST HOMECARE		FACILITY NUMBER:	198603108
ADMINISTRATOR:	RODERICK, TOM		FACILITY TYPE:	735
ADDRESS:	553 E 222ND ST		TELEPHONE:	(310) 989-8017
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY:	4	CENSUS: 4	DATE:	09/08/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	EBONEY JONES		TIME COMPLETED:	03:49 PM

ALLEGATION(S):

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Resident was physically abused while in care.

INVESTIGATION FINDINGS:

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On 09/08/21, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced complaint inspection visit at this facility, LPA was welcomed and met with house manager Eboney Jones and explained the purpose of today's visit was to gather information and conduct interviews regarding the allegation mentioned above. LPA notified the licensee and administrator Tom and Maria Roderick by telephone and was granted access to conduct the investigation.

The investigation consisted of the following: LPA interviewed staff #1-#6 (S1-S6), clients #1-#4 (C1-C4), witnesses #1-#5 (W1-W5). A review of (C1's) service records and other pertinent documents relevant to the nature of the complaint. A tour of the entire facility was conducted.

Evaluation Report continues on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021

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 11-AS-20210907161509

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: CARRIAGE CREST HOMECARE	FACILITY NUMBER: 198603108
	VISIT DATE: 09/08/2021

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Resident was physically abused while in care.

During this investigation, LPA reviewed C-1's service records and interviewed staff #1-#6 (S1-S6), clients #1-#4 (C1-C4), and witnesses #1-#5 (W1-W5) and found there is no evidence to support the allegation mentioned above.

It was alleged that (C1) was physically abused while in care. The complainant did not have a date, time, or location when the alleged incident occurred. The complainant reported the suspect was a female and uncertain if it is a staff member from this facility. The complainant was confident that no injuries were observed on 09/07/21 on (C1). The Department examined (C1) and found no apparent skin injury or discoloration on (C1’s) face or right shoulder where she indicated she was struck. During an interview with (C1), she stated that she was struck with an open hand across the face and was hit on her upper right shoulder by a male suspect. (C1) did not have the name of the suspect and reported the physical abuse happened in the evening while she was asleep. Later (C1) added, the incident occurred in her dream on 09/07/21, and unable to describe the male suspect. During the interview, (C1) would go in and out of sequence when she would explain the conditions of what happened during the incident 09/07/21.

An interview with (S1-S6) all claimed this allegation is false. (S1-S4) all say that they care a great deal and respect for their clients and that any type of abusive behavior is not acceptable. The co-administrator confirms no such thing ever occurred, nor conceived or attempted, and that all staff conducts a quarterly ethics training on how to deal with ethical dilemmas when one transpires.

(S1-S6) communicated that all staff conduct body checks daily and have not observed bruising or injuries on (C1). This would have been documented on (C1’s) progress notes as well and reported to the local regional center and adult and senior care division in writing with an incident report. An interview with (C2-C4) all expressed they like the home and that no one has experienced or witness any type of physical mistreatment from any staff. (C2 and C4) emphasized that they would notify another staff immediately if they ever encounter or observe such behavior.

Evaluation Reports continues on LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20210907161509

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: CARRIAGE CREST HOMECARE	FACILITY NUMBER: 198603108
	VISIT DATE: 09/08/2021

NARRATIVE

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An interview with witnesses (W1-W5) and found there is no immediate health or safety concern with the client’s total care at this facility and had all positive comments about the staff and how the home is being managed. Based on observation, record reviews, and interviews there's no evidence to corroborate the allegation mentioned above.

Based on information gathered, observation, interviews, service records, and other pertinent resources reviewed, there is no evidence to support the allegation: “Resident was physically abused while in care”

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.

No Deficiencies cited under California Code of Regulations Title 22.

An exit interview was conducted with the house manager Eboney Jones, and a copy of the report was provided by email.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021

LIC9099 (FAS) - (06/04)

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