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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 275202480
Report Date: 10/30/2025
Date Signed: 11/03/2025 12:08:34 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/01/2025 and conducted by Evaluator Vadim Gorban
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20250801152714
FACILITY NAME:CARMELO PARKFACILITY NUMBER:
275202480
ADMINISTRATOR:MAZERIK, MATTHEWFACILITY TYPE:
740
ADDRESS:966 CARMELO STREETTELEPHONE:
(831) 375-0665
CITY:MONTEREYSTATE: CAZIP CODE:
93940
CAPACITY:40CENSUS: 25DATE:
10/30/2025
UNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Lead staff Ana MartinezTIME COMPLETED:
05:05 PM
ALLEGATION(S):
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Resident sustained injuries due to staff neglect.
Facility staff failed to seek timely medical attention after the resident fell
INVESTIGATION FINDINGS:
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On 10/30/2025, Licensing Program Analyst (LPA) V. Gorban arrived unannounced to deliver findings on a complaint investigation. LPA explained the purpose of the visit to staff Anna Martinez and was allowed entry. Administrator was notified of Licensing visit.
During the course of the investigation, department conducted a facility tour, conducted interviews, and reviewed records.
On 07/30/2025, staff observed R1 trapped between the bed's side rail and the mattress, with his legs and feet touching the floor at 0500 hours. Staff placed R1 on the floor and did not seek medical attention until 0740 hours. R1 was diagnosed with temporary paralysis on the left side of his body, rhabdomyolysis, as well as bruising, skin tears, and swelling. Staff interviewed acknowledged that EMS should have been called immediately. The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. See citations on the attached LIC. 9099D. The issuance of additional civil penalties is pending and currently under review. The details of additional civil penalties will be outlined in a future report to the facility, if any. Exit Interview conducted. Appeal Rights provided.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025
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 2
Control Number 24-AS-20250801152714
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: CARMELO PARK
FACILITY NUMBER: 275202480
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2025
Section Cited
CCR
87411(a)
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87411 (a) Personnel Requirements – General - Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not observe das evidenced by:
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The facility administrator will provide details of formal staff termination letter. Also, administrator will provide a written statement letter that staff are able to follow facility protocol and make good decisions regarding resident care by POC due date to LPA by email.
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Based on records reviewed and interviews conducted, facility staff left R1 on the ground after finding R1 trapped by his torso between the bed's side rail and the mattress. This resulted in R1 sustaining temporary paralysis on the left side of his body, rhabdomyolysis, as well as bruising, skin tears, and swelling, which poses an immediate health and safety concern to the resident.
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Type A
10/31/2025
Section Cited
CCR
87411(d)(5)
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87411(d)(5) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (5) Knowledge necessary in order to recognize early signs of illness and the need for professional help.
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The facility administrator will provide staff on the job training regarding reside care by POC due date to LPA by email.
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Based on records reviewed and interviews conducted, facility staff failed to seek medical services after they found R1 trapped from a fall at 0500 hours. Staff placed R1 on the floor and waited until the house manager called EMS at 0740 hours, which poses an immediate health and safety concerns to the resident.
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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: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2