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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 370802857
Report Date: 08/25/2022
Date Signed: 08/25/2022 10:34:52 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/19/2022 and conducted by Evaluator Carmen Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20220719090116
FACILITY NAME:CARROLL'S COMMUNITY CAREFACILITY NUMBER:
370802857
ADMINISTRATOR:ROGELIO HERNANDEZFACILITY TYPE:
735
ADDRESS:523 EMERALD AVENUETELEPHONE:
(619) 442-8893
CITY:EL CAJONSTATE: CAZIP CODE:
92020
CAPACITY:70CENSUS: 67DATE:
08/25/2022
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Rogelio Hernandez, AdministratorTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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- Facility did not follow reporting requirements.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA identified herself and was granted entry by Rogelio Hernandez, Administrator. LPA stated the purpose of the visit and reviewed the findings of the complaint with Administrator Rogelio Hernandez.

The Department’s investigation consisted of interview with staff and records reviewed of relevant documents pertinent to this investigation. On July 19, 2022, it was alleged that facility did not report that client was admitted to the hospital.

During the review of client records, LPA observed that there was no incident report made to the Department to report that client had been held at the hospital. During interview with staff, staff did confirm that there was no report made to the Department to report that client had been held at the hospital.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022
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 08-AS-20220719090116
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: CARROLL'S COMMUNITY CARE
FACILITY NUMBER: 370802857
VISIT DATE: 08/25/2022
NARRATIVE
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Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during staff and outside source interviews and records reviewed, there is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099D.

The report was discussed, a plan of correction was jointly developed, and an exit interview was conducted with Administrator Rogelio Hernandez. A copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) was provided to Administrator Hernandez at the conclusion of the visit. The signature below confirms the documents were received.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 08-AS-20220719090116
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CARROLL'S COMMUNITY CARE
FACILITY NUMBER: 370802857
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2022
Section Cited
CCR
80061(b)(1)(D)
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80061 Reporting Requirements (b)(1)(D) Any injury to any client which requires medical treatment.… this requirement was not met as evidenced by:
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Administrator will submit an IR for client and continue to report incidents. Staff will be trained on reporting requirements. Certificate of completion for staff will be submitted to LPA by POC due date, 9/15/22.
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Based on interviews and records review, the facility did not report that C1 was medically treated at the hospital for 1 out of 67 clients in care. This posed a potential safety risk to 1 of 67 of clients 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.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3