372004242-5-15-2026-08-AS-APAO-DUEPYM-20260525114409

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 372004242
Report Date: 05/15/2026
Date Signed: 05/15/2026 12:13:14 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
04/02/2026 and conducted by Evaluator Janet Ngallo

COMPLAINT CONTROL NUMBER: 08-AS-20260402085610

FACILITY NAME:	CARPEL BOARD AND CARE FACILITY		FACILITY NUMBER:	372004242
ADMINISTRATOR:	CARMONA, LEONOR		FACILITY TYPE:	740
ADDRESS:	2073 HANFORD DRIVE		TELEPHONE:	(858) 569-1691
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92111
CAPACITY:	6	CENSUS: 4	DATE:	05/15/2026
		UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Licensee Leonor Carma		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Staff handled a resident roughly, resulting in injury to the resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced subsequent visit to deliver findings regarding the above-mentioned allegation. LPA identified themselves and met with Licensee Leonor Carmona to discuss the purpose of the visit and elements of the complaint.

On 04/02/2026, it was alleged that staff handled a resident roughly, resulting in injury. The department's investigation consisted of interviews and records review.

Regarding the allegation, staff consistently reported that the resident(R1) exhibited ongoing combative behaviors, including hitting, spitting, swinging limbs, throwing objects, attempting to leave the facility, and resisting care. Staff stated that when assistance was required for changing or redirection, multiple staff occasionally provided support due to R1's strength and resistance but denied using rough handling. Staff reported no injuries observed on R1.
(Cont. on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Janet Ngallo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20260402085610

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CARPEL BOARD AND CARE FACILITY	FACILITY NUMBER: 372004242
	VISIT DATE: 05/15/2026

NARRATIVE

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(Cont. from LIC 9099)

An interview with an outside source (OS1) reported that R1 had a history of making claims that others are “hurting” or “pushing” them when resisting care or direction, including in situations involving OS1 and family members. OS1 further reported that during visits at the hospital after R1's admission, they did not observe any bruising or marks on R1's body. OS1 stated they did not believe facility staff caused harm and described staff interactions observed as consistent with efforts to assist a resident who was rejecting care.

Records reviewed indicated that the resident was admitted with diagnoses including dementia and psychotic disturbance and required some assistance with ADLs and mobility. Facility notes documented episodes of restlessness, combative behaviors, and refusal of redirection in the days leading up to hospitalization. No care plan, physician’s report, or MAR could be reviewed; the licensee was cited in a separate visit for incomplete recordkeeping.

Based on interviews and records review, the preponderance of evidence standard has not been met, therefore the above allegation is found to be unsubstantiated. An exit interview was conducted with Licensee Leonor Carmona and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided. Their signature confirms receipts of these documents.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Janet Ngallo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026

LIC9099 (FAS) - (06/04)

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