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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306000295
Report Date: 10/03/2022
Date Signed: 10/03/2022 10:24:38 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/02/2022 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20220902113459
FACILITY NAME:KARLTON RESIDENTIAL CARE CENTERFACILITY NUMBER:
306000295
ADMINISTRATOR:ELENA WEINERFACILITY TYPE:
740
ADDRESS:3615 WEST BALL RD.TELEPHONE:
(714) 236-1170
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:76CENSUS: 51DATE:
10/03/2022
UNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Elena WeinerTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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9
Facility did not issue refund.
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry by Administrator Elena Weiner and explained the reason for the visit.
During the course of the investigation, LPA toured the facility, interviewed staff and witness as well as reviewed and obtained pertinent information such as facility billing invoice. Regarding the allegation that facility did not issue refund, the investigation revealed the following: Resident 1 (R1) resided at the facility from 06/08/2022 through 6/17/2022. Resident was sent out to the hospital on 06/17/2022 and family moved resident out of the facility without a written thirty day notice. Per health and safety code, a refund of 80 percent of the preadmission fee, minus $500, is due back if resident moves out within the first month. Facility did not refund any money to the resident's responsible party. Based on observations made and interviews conducted, 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, Chapter 8) are being cited on the attached LIC 9099D.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2022
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 22-AS-20220902113459
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: KARLTON RESIDENTIAL CARE CENTER
FACILITY NUMBER: 306000295
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2022
Section Cited
HSC
1569.651(h)(2)
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If the resident leaves the facility for any reason during the first month of residency, the resident shall be entitled to a refund of at least 80 percent of the preadmission fee amount in excess of five hundred dollars ($500). This req is not being met as evidenced by:
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Licensee refunded $700 to resident/ responsible party on 09/08/2022. CLEARED.
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Based on interviews conducted, Licensee failed to ensure resident/ responsible party received a refund for 80 percent of preadmission fee. This poses a potential health and safety risk to residents in care.
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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.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/02/2022 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20220902113459

FACILITY NAME:KARLTON RESIDENTIAL CARE CENTERFACILITY NUMBER:
306000295
ADMINISTRATOR:ELENA WEINERFACILITY TYPE:
740
ADDRESS:3615 WEST BALL RD.TELEPHONE:
(714) 236-1170
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:76CENSUS: DATE:
10/03/2022
UNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:TIME COMPLETED:
10:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not seek medical attention in a timely manner.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry by Administrator Elena Weiner and explained the reason for the visit.
During the course of the investigation, LPA toured the facility, interviewed staff and witness as well as reviewed and obtained pertinent information such as physician report. Regarding the allegation that staff did not seek medical attention in a timely manner, the investigation revealed the following: On 06/17/2022, R1's family indicated to staff that R1 appeared off and did not look good. Family member requested resident be sent out to the hospital. Staff attempted to call a private ambulance service to which no ambulance was available. Staff called 911 and resident was sent out. Staff state that approximately 5 minutes went by between conversation with family and 911 being called. Witness confirms 911 was called and resident was sent out. Facility does not document times residents are sent out via 911. Due to conflicting information, LPA is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with and a copy of this report was provided
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3