370804865-6-19-2025-08-AS-SJAB-DJKUYR-20250714160022

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 370804865
Report Date: 06/19/2025
Date Signed: 06/19/2025 04:47:19 PM

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
04/28/2021 and conducted by Evaluator Dang Nguyen

COMPLAINT CONTROL NUMBER: 08-AS-20210428121106

FACILITY NAME:	CARROLLS RESIDENTIAL CARE		FACILITY NUMBER:	370804865
ADMINISTRATOR:	BRYAN MEYERS		FACILITY TYPE:	740
ADDRESS:	655 S MOLLISON		TELEPHONE:	(619) 444-3181
CITY:	EL CAJON	STATE: CA	ZIP CODE:	92020
CAPACITY:	0	CENSUS: 0	DATE:	06/19/2025
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	N/A. Report Certified Mailed to Licensee.		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility staff mismanaged resident's medication, resulting in hospitalization.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Dang Nguyen concluded an investigation regarding the above prior complaint allegation. Since the facility ceased operations on 07/19/2023 due to Change of Ownership, the allegation finding was delivered to the Licensee via USPS certified mail.

The Complainant alleged that facility staff mismanaged Resident #1’s (R1’s) medication, resulting in hospitalization. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] CCLD’s investigation involved an unannounced a virtual facility tour/welfare check via video (as per Department policy during this phase of the COVID-19 pandemic), interviews of relevant staff, and review of a pertinent facility records, ambulance records, and hospital records.

[CONTINUED ON LIC 9099-C, 1 of 2]

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025

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 4

Control Number 08-AS-20210428121106

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: CARROLLS RESIDENTIAL CARE	FACILITY NUMBER: 370804865
	VISIT DATE: 06/19/2025

NARRATIVE

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[CONTINUED FROM LIC 9099]

The same day of the incident, Licensee self-submitted to CCLD a written Incident Report. This report, along with interviews of facility management and medication technician Staff #1 (S1), closely aligned to show: R1 had lived at the facility less than a week when the incident occurred. Resident #2 (R2) was also new to the facility. S1 was not familiarized with R1 and R2. On 04/27/2021 around 8:00 AM, S1 entered the bedroom of R1 and gently woke R1 from their sleep to give their morning medication. S1 asked R1 for their name, but R1, who just woke up, was so soft-spoken that S1 could not clearly hear their speech. S1 then asked R1 if they were R2, using a yes/no binary question, to which R1 nodded yes. S1 then handed over and R1 ingested one (1) 200 mg Clozaril tablet (an antipsychotic medication) which did not belong to R1 (it was instead prescribed to R2). When exiting the bedroom, S1 observed the name plate on the door and quickly recognized that they had given R1 the wrong medication.

S1 immediately reported the medication error to facility management, who timely notified R1’s psychiatrist and R1’s responsible person. They also notified R1 themselves of what had happened to them. R1’s psychiatrist instructed to continue observing R1 for possible adverse symptoms and to arrange for hospital care if such appeared. Over the next two hours, facility staff indeed checked on R1 roughly every fifteen minutes. Initially, R1 had no symptoms. Around 9:30/10:00 AM, staff observed R1 increasingly drowsy with slurred speech and poor balance, thus arranging for ambulance transport of R1 to the hospital.

Ambulance records showed: Upon arrival, Emergency Medical Technicians (EMTs) found R1 lethargic, able to state only their name and nothing else. R1 was able to squeeze an EMT’s hand when prompted to. R1 appeared short of breath and their oxygen saturation varied from 89% to 94%, for which R1 was connected to supplemental oxygen at a flow rate of 2 liters per minute. R1’s other vital signs were within normal ranges. EMTs then moved R1 to their ambulance via stretcher.

[CONTINUED ON LIC 9099-C, 2 of 2]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 08-AS-20210428121106

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: CARROLLS RESIDENTIAL CARE	FACILITY NUMBER: 370804865
	VISIT DATE: 06/19/2025

NARRATIVE

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[CONTINUED FROM LIC 9099-C, 1 of 2]

Hospital Records showed: Upon arrival to the Emergency Department, R1 was non-verbal. R1’s heart rate was low at 54 beats per minute, but their oxygen saturation was now at 98% and supplemental oxygen was discontinued. R1’s blood pressure was low at 98/53 but soon went back to normal range after R1 received intravenous (IV) fluids. Some of R1’s routine medications were held/paused, while R1 continued to be observed over three (3) days, during which time their mentation gradually improved with just time and rest. The hospitalist physician diagnosed R1 with “acute toxic encephalopathy due to Clozapine” and “sinus bradycardia likely medication induced.” By 04/29/2021, R1 was able to converse and confirmed to hospital staff that they had earlier ingested an incorrect medication. By 04/30/2021, R1 was released/discharged from hospital care at their baseline level of health.

The above 04/27/2021 medication error affected only R1. It did not preclude R2 from receiving their regularly prescribed medication that day.

Based on records and interviews, a preponderance of evidence exists to show facility staff mismanaged R1’s medication, resulting in hospitalization. Since the violation resulted in acute/temporary illness to R1, an Immediate Civil Penalty of $500 was assessed/charged to Licensee (refer to the LIC421-IM page). However, since R1 did not suffer lasting illness/injury from this incident and since hospital staff were essentially able to resolve R1’s symptoms with IV fluids and rest/time, an additional Enhanced Civil Penalty was not assessed.
Per interviews, facility management provided S1 with one-on-one medication assistance retraining on 05/11/2021, resolving the immediate risk. The facility has since closed and ceased operations. No further Plan of Correction was formed with the Licensee.

A copy of this report, the LIC9099-D page, the LIC421-IM page, and the Licensee/Appeal Rights (LIC9058 03/22) were mailed to the Licensee’s last known address via USPS certified mail.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20210428121106

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: CARROLLS RESIDENTIAL CARE	FACILITY NUMBER: 370804865
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/19/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/19/2025 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care: “(a)(4) The licensee shall assist residents with self-administered medications as needed.” This requirement was not met, as evidenced by:	1 2 3 4 5 6 7	Per interviews, facility management provided S1 with one-on-one medication assistance retraining on 05/11/2021, resolving the immediate risk. The facility has since closed and ceased operations. No further Plan of Correction was formed with the Licensee.
	8 9 10 11 12 13 14	Based on records and interviews, Licensee did not assist 1 of 110 residents (R1) with self-administered medication as it was prescribed. This posed an immediate health risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025

LIC9099 (FAS) - (06/04)

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