270708695-4-10-2022-26-AS-KHOS-CFKHVT-20220620063224

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 270708695
Report Date: 04/10/2022
Date Signed: 04/10/2022 01:30:56 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/20/2020 and conducted by Evaluator Jaclyn Avila

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20201120155158

FACILITY NAME:	AGAPE OF CARMEL		FACILITY NUMBER:	270708695
ADMINISTRATOR:	FICKEWIRTH, MIRIAM		FACILITY TYPE:	740
ADDRESS:	25527 FLANDERS DRIVE		TELEPHONE:	(831) 626-1032
CITY:	CARMEL	STATE: CA	ZIP CODE:	93923
CAPACITY:	6	CENSUS: 5	DATE:	04/10/2022
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Miriam Fickewirth		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility staff did not seek medical attention
Facility staff not following doctors orders
Facility did not provide proper notice of fee increase

INVESTIGATION FINDINGS:

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On 4/10/2022, Licensing Program Analyst (LPA) Jaclyn Avila conducted an unannounced complaint investigation visit regarding the above allegations and met with Miriam Fickewirth Administrator/Licensee. Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical mask

California Department of Social Services (CDSS) Community Care Licensing (CCL) has investigated this complaint and found the allegation(s) to be unfounded. This department has reviewed the admission agreement signed by both licensee and conservator dated 2/25/2019. On 1/27/2020, Licensee provided Conservator with a memo stating there would be a rate increase due to level of care now needed due to a decline in the resident. On page 7 of the admission agreement initialed by the conservator, the agreement states the resident or responsible party will be notified within 2 days of a change of condition requiring additional care which the facility did as per the signed agreement.
Cont'd on 9099-C

Unfounded

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2022

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 26-AS-20201120155158

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: AGAPE OF CARMEL	FACILITY NUMBER: 270708695
	VISIT DATE: 04/10/2022

NARRATIVE

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The licensee upon noticing signs and symptoms of an infection, contacted the resident’s doctor as required by regulation. The doctor prescribed medication which was given as directed by the doctor beginning 11/13/2020. When licensee noticed the medication was not effective the licensee had the resident sent to the hospital on 11/16/2020. The licensee responded appropriately to the needs of the resident.

Unfounded: This agency has investigated the complaint alleging: Facility staff did not seek medical attention, Facility staff are not following doctor’s orders, and Facility did not provide proper notice of fee increase. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2022

LIC9099 (FAS) - (06/04)

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