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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005680
Report Date: 07/14/2021
Date Signed: 07/14/2021 04:15:54 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CARNELIAN VILLASFACILITY NUMBER:
306005680
ADMINISTRATOR:STRUVE, JINGFACILITY TYPE:
740
ADDRESS:1773 S. CARNELIAN STREETTELEPHONE:
(714) 860-4490
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY:6CENSUS: 4DATE:
07/14/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Cherie WoodTIME COMPLETED:
04:30 PM
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the following incidents self-reported by the Licensee: physical abuse of residents by facility staff, neglect/lack of care and supervision resulting in residents sustaining injuries, not providing timely medical treatment, and not properly reporting incidents. LPA met with Administrator Cherie Wood and explained the reason for today’s inspection. The investigation into the above allegations was conducted by Community Care Licensing Investigations Branch (IB) and revealed the following:

During the course of the investigation, interviews were conducted with Administrator Wood, Licensee Jing Struve, facility staff, witnesses, and residents. Additionally, copies of bank statements, credit card statements, financial statements, medical records, and a police report were obtained and reviewed.

Resident #1 (R1) and Resident #2 (R2) both reside at Carnelian Villas and reported on separate occasions physical abuse by former caregivers who are married identified as Staff #1 (S1) and Staff #2 (S2). S1 and S2 resided at the facility during their employment and managed the facility with little to no supervision by Licensee Struve and Administrator Wood. Caregiver S2 was never cleared to work at the facility and had an exclusion for physical abuse. On 01/29/21, Licensee Struve discovered bruising on R1’s hands and wrist and noticed a swollen black eye. Licensee Struve inquired to both caregivers about the multiple bruises R1 sustained and they informed her that R1 fell off the bed. Licensee Struve asked R1 about their injuries and they requested to be moved to another facility then after their move they reported being physically abused by caregiver S2.

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SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: CARNELIAN VILLAS
FACILITY NUMBER: 306005680
VISIT DATE: 07/14/2021
NARRATIVE
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On 03/08/21, Licensee Struve noticed bruising on R2’s wrist and asked them about the injuries and R2 informed her that the caregiver identified as S2 hit them several times on their wrist and on the back of their hand. Licensee Struve questioned caregivers S1 and S2 and they denied any misconduct with the residents. Licensee Struve terminated the caregivers on 03/08/21.

Licensee Struve was made aware of the physical abuse in January after R1 disclosed their fear of the caregivers and after sustaining unexplainable bruises to their wrist, legs, forehead and a purple/bluish bruise to their left eyelid. However, Licensee Struve had R1 medically assessed two weeks later on 02/03/2021. Licensee Struve admitted that she was fearful of S1 and S2 and did not report the abuse and failed to protect the residents, she did not provide any timely medical attention to any of the injuries they sustained and failed to report the abuse to law enforcement immediately or to Licensing. There is admission and enough information to the support the findings, therefore, this case is substantiated.

Based on the observations made during this investigation, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Civil penalties in the amount of $500 are being assessed because a staff member worked over 5 days without a clearance transfer. See LIC421BG. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

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SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
LIC809 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: CARNELIAN VILLAS
FACILITY NUMBER: 306005680
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/15/2021
Section Cited

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87468.2 … Personal Rights … (a) … residents … shall have all of the following personal rights: (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not being met as evidenced by:
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Based on interviews and records, the licensee did not prevent S1 and S2 from physically abusing R1 and R2, which poses an immediate health, safety, and personal rights risk to persons in care.
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Type A
07/15/2021
Section Cited

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87468.2 … Personal Rights … (a) … residents … shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in … personal care and assistance, visits, communications…, and meetings... This requirement is not being met as evidenced by:
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Based on interviews, the licensee did not ensure R2’s privacy during visits and meetings and allowed S1 and S2 to always be present to intimidate and prevent R2 from reporting their abuse earlier, which poses an immediate health, safety, and personal rights risk to persons in care.
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and this notice will also be added to the back of the admission agreement. Licensee will send proof of training and proof of sending the notice to LPA by POC due date.
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: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2021
LIC809 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: CARNELIAN VILLAS
FACILITY NUMBER: 306005680
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/15/2021
Section Cited

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87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not being met as evidenced by:
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Based on interviews and records, the licensee noted R1’s injuries on 01/19/2021 but did not seek immediate medical attention for R1’s bruised forehead and eye, which poses an immediate health, safety, and personal rights risk to persons in care.
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Type A
07/15/2021
Section Cited

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87405 Administrator ... Duties. (a) .... The administrator … shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility .... there shall be coverage by a designated substitute … responsible and accountable for management and administration …
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This requirement is not being met as evidenced by: Based on interviews, the licensee and administrator were afraid of S1 and S2, did not supervise the care provided by S1 and S2, and did not properly manage the facility, which poses an immediate health, safety, and personal rights risk to persons 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: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2021
LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: CARNELIAN VILLAS
FACILITY NUMBER: 306005680
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/15/2021
Section Cited

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87211 Reporting Requirements (c) Any suspected physical abuse that does not result in serious bodily injury … shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours... This requirement is not being met as evidenced by:
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Based on interviews and documents, the licensee suspected physical abuse by S1 and S2 as early as 01/2021 but did not report the abuse until the report to licensing on 04/01/2021, which poses an immediate health, safety, and personal rights risk to persons in care.
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Type A
07/15/2021
Section Cited

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87355 Criminal Record Clearance: (e) All individuals subject to a criminal record review ... shall prior to working ... (1) Obtain a California clearance or a criminal record exemption... This requirement was not met as evidenced by:
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Based on records, the licensee did not ensure S2 was background cleared prior to working at the facility and allowed S2 to work for months without a clearance, which poses an immediate health, safety, and personal rights risk to persons 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: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2021
LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: CARNELIAN VILLAS
FACILITY NUMBER: 306005680
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/15/2021
Section Cited

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(a) … (3) Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California. This requirement is not being met as evidenced by:
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Based on interviews and records, the licensee intentionally did not comply with the Department’s order excluding S2 by knowingly hiring S2 and allowing S2 to provide care for months, which poses an immediate health, safety, and personal rights risk to persons 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: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2021
LIC809 (FAS) - (06/04)
Page: 6 of 6