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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604489
Report Date: 05/10/2024
Date Signed: 05/10/2024 12:14:13 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
04/15/2024 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20240415153129
FACILITY NAME:AVALON PALM CARE, INC. DBA AVALON PALMFACILITY NUMBER:
374604489
ADMINISTRATOR:WINBLAD, JASONFACILITY TYPE:
740
ADDRESS:3271 INNUIT AVETELEPHONE:
(619) 757-3918
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY:6CENSUS: 6DATE:
05/10/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator Carmen CampasTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not ensure the facility was free from mold
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced follow up complaint investigation visit, and delivered complaint findings. The LPA introduced himself and disclosed the purpose of the visit to Administrator Carmen Campas.

Throughout the investigation, the Department secured records and conducted interviews with external and internal sources, including staff and residents.

It was alleged staff did not ensure the facility was free from mold. On 04/15/2024, it was reported to the Department a source had witnessed a mildew smell in a resident’s bedroom. Interviews with both internal and external sources did not reveal any concerns with mold, nor similar smells emanating from resident bedrooms. On several visits to the facility, the LPA tour the facility, including the room in question, and did not witness any mildew, nor odors emanating from the rooms.
(See LIC 9099C for continuation of report.)
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
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 2
Control Number 08-AS-20240415153129
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: AVALON PALM CARE, INC. DBA AVALON PALM
FACILITY NUMBER: 374604489
VISIT DATE: 05/10/2024
NARRATIVE
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An interview with the administrator revealed a previous resident occupying the room in question may have stored a large amount of a dietary supplement, which could have contributed to the alleged smell. Staff, along with the LPA observation, confirmed bedroom windows were frequently opened to avoid odors.

Based on the evidence obtained, there was not enough evidence to prove the alleged violation occurred, therefore, the allegation was Unsubstantiated.

An exit interview was conducted with Administrator Campas, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058), were provided.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
LIC9099 (FAS) - (06/04)
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