374603961-6-2-2023-08-AS-SJAB-CT2TLV-20230622145008

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603961
Report Date: 06/02/2023
Date Signed: 06/02/2023 02:07:03 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 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
11/12/2020 and conducted by Evaluator Daniel Pena

COMPLAINT CONTROL NUMBER: 08-AS-20201112100552

FACILITY NAME:	UNLICENSED - EDITA CARLSON		FACILITY NUMBER:	374603961
ADMINISTRATOR:	EDITA CARLSON		FACILITY TYPE:	740
ADDRESS:	520 CARDIFF STREET		TELEPHONE:	(999) 999-9999
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92114
CAPACITY:	5	CENSUS: 4	DATE:	06/02/2023
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Edita Carlson, Operator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Unlicensed Care

INVESTIGATION FINDINGS:

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On 6/2/2023, at about 12:30 PM, Licensing Program Analyst (LPA), Daniel Pena conducted a complaint visit at 520 Cardiff St., San Diego, CA 92114 to conclude an investigation into the abovementioned allegation. After introducing himself and presenting his department identification, LPA was allowed entry into the Independent Living Facility (ILF) by Tenant, Ron Murillo. Owner/Operator Edita Carlson arrived shorty after and LPA discussed the purpose of the visit.

During the visit, LPA assessed three of the four tenants and all were deemed independent. Interviews with tenants and Operator Carlson verified that the fourth tenant, who was at day program, is also indepednent.

On 11/12/2020, it was alleged unlicensed care was provided at 520 Cardiff Street, San Diego. The Department's investigation included, LPA observation, outside source record reviews, and interviews with tenants, Operator, and outside sources. An outside source reported three tenants resided at the Cardiff Street property: one elderly. This tenant was observed in a wheelchair, and according to the

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

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-20201112100552

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: UNLICENSED - EDITA CARLSON	FACILITY NUMBER: 374603961
	VISIT DATE: 06/02/2023

NARRATIVE

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outside source, needed assistance with Activities of Daily Living (ADL). According to the source, the tenant was incontinent and disheveled in appearance.

On 11/18/20, LPA and representatives from an outside agency conducted a virtual visit to the facility, due to COVID-19. T1 could not be assessed due to an inability to communicate. The other tenants were deemed independent by observation and interviews.

Operator, Carlson was interviewed and told LPA that T1 was dropped off at the ILF while Carlson was not home. Tenant interviews corroborated this. Operator, Carlson was not provided any documentation but noticed T1 was in a wheelchair. Concerned, Carlson contacted the placement agency to tell them T1 needs to be completely independent to reside at the ILF. According to Carlson, the agency was unresponsive. When asked, Carlson denied providing T1 assistance during their brief stay at the ILF.

A hospice agency source was interviewed and stated that they assessed T1 for hospice on 11/21/20 at the Cardiff Street ILF. It was the hospice agency’s determination that T1 was fit to reside at the ILF. The hospice source intimated to LPA, they have assessed clients for ILF and assisted living facilities for several years. It was the source’s, professional opinion T1 was declining but independent. T1 could ambulate but was beginning to have falls. T1 was able to properly use a walker and ambulate to the bathroom on their own. The source observed that T1's medications were stored in their room under T1’s control. The source said T1 was alert and verbal. The source said T1 was incontinent, but they were able to change themselves as needed. T1 was able to eat and make daily appointments. The source said T1 had a cell phone and was able to use it. The source stated, at the time of T1’s assessment, T1 was fit to reside at the ILF. However, the source also said T1 would not have been deemed independent if they were assessed 2-3 months later, due to their declining condition.

Investigation revealed, T1 was transferred to a licensed care facility on 11/23/20 and to a Skilled Nursing Facility (SNF) in March 2021. Records and interviews provided evidence T1 required assistance with some ADLs. However, it could not be determined that care was provided to T1 during their stay at the ILF.

Based on the information obtained in this investigation, including LPA observation, outside source record review, and tenant, operator and outside source interviews, there is insufficient evidence to prove unlicensed care was provided to T1. The preponderance of evidence standard was not met. Therefore, the

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20201112100552

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: UNLICENSED - EDITA CARLSON	FACILITY NUMBER: 374603961
	VISIT DATE: 06/02/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	allegation is determined to be Unsubstantiated. An exit interview was conducted with ILF Operator, Carlson and a copy of this report was provided and signature on this form confirms receipt of the report.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC9099 (FAS) - (06/04)

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