405801701-10-23-2023-29-AS-KBUY-CX5KES-20231031075050

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405801701
Report Date: 10/23/2023
Date Signed: 10/23/2023 09:45:27 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
06/22/2023 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20230622164857

FACILITY NAME:	C.A.L.L.-CARMELITA HOUSE		FACILITY NUMBER:	405801701
ADMINISTRATOR:	BRENDA VICTORIA		FACILITY TYPE:	740
ADDRESS:	2660 FERROCARRIL		TELEPHONE:	(805) 466-8502
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY:	6	CENSUS: 6	DATE:	10/23/2023
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Intin Adminstrator Valerie Braisher-King		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Facility staff are not qualified.
Facility does not have an administrator.
Facility staff are not ensuring that residents attend their appointments.

INVESTIGATION FINDINGS:

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On 10/23/2023 at 9:00am, Licensing Program Analyst (LPA) Jeffries conducted an unannounced follow-up visit to deliver final findings on the original complaint dated 6/22/2023. LPA met with Intin Adminstrator Valerie Braisher-King and explained the purpose of the visit.

On the allegations, “Facility staff are not qualified” and “Facility does not have an administrator,” the complainant’s concern was that the facility’s administrator left on 6/20/2023 and there was no replacement or backup lead staff in place. LPA interviewed staff who indicated the licensee’s president was at the facility on 6/20/2023 and the Office Manager was at the facility on 6/21/2023 to help with medications. During LPA Chavez visit on 6/23/2023, LPA Chavez notified the facility they would need a replacement administrator, and the Office Manager indicated they were preparing the paperwork for another administrator to take over. LPA Chavez received the paperwork and updated the administrator on record.
CONTINUED on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023

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-20230622164857

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: 10/23/2023

NARRATIVE

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The facility also had two other administrators of the licensee’s other facilities designated as on-call administrators. Based on the information obtained, the allegation is deemed Unsubstantiated at this time.

On the allegation, “Facility staff are not ensuring that residents attend to their appointments,” the complainant’s concern was that because there was no administrator, the residents missed appointments. LPA Chavez interviewed Office Manager on 6/23/23. Office manager showed LPA Chavez a desk calendar with appointments. The calendar showed Resident 1 (R1) has an appointment on 6/28/23. The Office Manager stated she was trying to figure out where things were after the former administrator left on 6/20/23, and believed the appointments scheduled were on the desk calendar. However, no one was able to access the former administrator’s work cell phone, which could have appointments in it, but this was not confirmed. LPA Jeffries interviewed S6 who was working during the time of complaint, and confirmed no appointments were missed. LPA Jeffries could not find any documentation indicating appointments were missed. Based on the information obtained, the allegation is deemed Unsubstantiated at this time.

Exit interview, report given.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023

LIC9099 (FAS) - (06/04)

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