405801701-10-6-2022-29-AS-KBUY-CJYSZS-20221007141938

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405801701
Report Date: 10/06/2022
Date Signed: 10/06/2022 11:46:53 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/03/2021 and conducted by Evaluator Darlene Chavez

COMPLAINT CONTROL NUMBER: 29-AS-20211103102612

FACILITY NAME:	C.A.L.L.-CARMELITA HOUSE		FACILITY NUMBER:	405801701
ADMINISTRATOR:	COURTNEY MOORE		FACILITY TYPE:	740
ADDRESS:	2660 FERROCARRIL		TELEPHONE:	(805) 466-8502
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY:	6	CENSUS: 4	DATE:	10/06/2022
		UNANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	Susan Samayoa, Lead Caregiver		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff not providing adequate supervision to resident in care.

INVESTIGATION FINDINGS:

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On 10/06/22 at 10:35 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced complaint visit to deliver final findings to the facility listed above. LPA met with Susan Samayoa, Lead Caregiver, and explained the purpose of the visit.

On the allegation “Staff not providing adequate supervision to resident in care,” the complainant’s concern was that Resident #1 (R1) was observed slumped over in their wheelchair for at least 30 minutes and staff did not help.” To investigate the allegation, LPA interviewed the supervisor, staff, and credible witnesses, and made observations.

On 11/05/21 at 12:19 pm and on 9/29/22 at 12:25 pm, LPA interviewed Brenda Victoria, Supervisor. Supervisor states that resident R1 was in the hospital for 2-3 months prior to being admitted to the facility. Supervisor explains “R1 had a lot of medical problems and slumped in their chair at times due to multiple medical issues.” Supervisor says that staff would sit R1 up, and R1 would slump again. Continued on 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022

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 29-AS-20211103102612

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: C.A.L.L.-CARMELITA HOUSE	FACILITY NUMBER: 405801701
	VISIT DATE: 10/06/2022

NARRATIVE

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On 9/29/22 at 12:03 pm, LPA visited the facility and observed three staff caring for four residents. Staff assisted residents with lunch and cleaning-up after lunch. Residents appeared to be taken care of by staff who assisted with their needs.

On 9/29/22 at 12:16 pm, LPA interviewed Staff #1 (S1). S1 says that there are always three staff working in the facility when all residents are present. S1 says that when R1 was in the facility, S1 witnessed “R1 leaning in their chair sometimes and staff and I propped R1 up with pillows.” At 12:47 pm, LPA interviewed Staff #2 (S2). S2 says that most of the time, R1 was in pain and sometimes R1 was in a wheelchair, sometimes in bed. S2 explains that R1 was weak and leaned in their wheelchair or recliner. S2 says they placed pillows to prop R1 up. A 12:55 pm, LPA interviewed Staff #3 (S3). S3 says that sometimes R1 was in a wheelchair and other times in bed or a recliner. S3 says R1 was “losing balance and leaning in the chair.” S3 says when R1 leaned in the chair, S3 and staff put pillows behind or beside R1 to hold R1 up. S3 says they sat, most times, in the living room watching over residents in addition to checking on them at least every 20-30 minutes. At 1:14 pm, LPA interviewed Staff #4 (S4). S4 says R1’s health went up and down and that “R1 sometimes was sliding out of the chair, then I would prop R1 up, then place pillows on R1’s side(s).” S4 says that R1 was more stable in the recliner and didn’t lean as much.

On 9/30/22 at 11:24 am, LPA spoke with a credible Witness #1 (W1). W1 says they visited the facility in December of 2021 and did not witness R1 slumped in their chair nor did W1 notice anything out of the ordinary.

On 10/05/22 at 3:22 pm, LPA spoke with a credible Witness #2 (W2). W2 states that the times they have gone to the facility, the facility had adequate staffing, staff appeared engaged and helping and in a couple cases over-staffed. W2 says “I do not see the staff sitting around talking, they are not on their cell phones. I think it is a very demanding and hands-on environment.”

Based on the evidence obtained, the allegation “Staff not providing adequate supervision to resident in care,” is deemed Unsubstantiated at this time. Interviews and observations reveal that staff are assisting residents’ needs and in a timely manner.

Exit interview conducted and a copy of the report emailed to the Executive Director and Supervisor.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022

LIC9099 (FAS) - (06/04)

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