425801219-2-12-2021-29-AS-KBUY-BZ2RN9-20210312120959

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425801219
Report Date: 02/12/2021
Date Signed: 02/12/2021 01:25:03 PM

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
11/05/2019 and conducted by Evaluator Lyndia Sager

COMPLAINT CONTROL NUMBER: 29-AS-20191105121816

FACILITY NAME:	CARPINTERIA SENIOR LODGE		FACILITY NUMBER:	425801219
ADMINISTRATOR:	JOY KINGSTON		FACILITY TYPE:	740
ADDRESS:	4650 7TH STREET		TELEPHONE:	(805) 566-5364
CITY:	CARPINTERIA	STATE: CA	ZIP CODE:	93013
CAPACITY:	6	CENSUS: 3	DATE:	02/12/2021
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Joy Kingston		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Allegation #1: Licensee failed to accord dignity in resident’s personal relationships with staff, residents, and others.
Allegation #2: Licensee failed to ensure resident was free from punishment, humiliation, intimidation, abuse, or other actions.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Lyndia Sager conducted a subsequent complaint investigation to deliver final investigation findings telephonically with Joy Kingston, Licensee/Administrator, due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures.
Throughout the course of this investigation, LPA Kontilis and LPA Sager conducted interviews with Licensee/Administrator, staff, residents, witnesses, Long Term Care Ombudsman (LTCO) and Adult Protective Services (APS).

On 11/01/19, while waiting for a medical appointment, a credible witness observed the Licensee/Administrator grab the back of Resident #1’s (R1) wheelchair with force and whipped the wheelchair around. The Licensee/Administrator pointed her finger at (R1) and scolded (R1) for attempting to wheel herself to the front desk. Another credible witness also observed the same behavior along with noting the Licensee/Administrator shoved (R1) in her wheelchair while scolding her to wait for her appointment. During the medical appointment, (R1) was observed to be crying, fearful, and asking for help. (see next page 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Lyndia Sager	TELEPHONE: (805) 680-7683
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2021

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-20191105121816

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: CARPINTERIA SENIOR LODGE	FACILITY NUMBER: 425801219
	VISIT DATE: 02/12/2021

NARRATIVE

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Information obtained through other interviews revealed that the Licensee/Administrator has a loud voice, at times loses patience with the residents, and yells. Licensee/Administrator was interviewed and denied the allegations.

Based on the information obtained during the course of the investigation, including information from reliable witnesses, the allegations above are deemed substantiated.

Deficiency issued on 9099-D, telephonic exit interview was conducted with the Administrator, and a copy of the report was provided via email for signature. Appeal Rights emailed.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Lyndia Sager	TELEPHONE: (805) 680-7683
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2021

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20191105121816

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: CARPINTERIA SENIOR LODGE	FACILITY NUMBER: 425801219
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/12/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/22/2021 Section Cited HSC 1569.269(a)(10)	1 2 3 4 5 6 7	H&S 1569.269 (a)(10) Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (10) To be free from...humiliation, intimidation, and verbal, mental, physical, ...abuse. This requirement is not met as evidenced by:	1 2 3 4 5 6 7
	8 9 10 11 12 13 14	Based on interviews, the Licensee failed to ensure that (R1) was treated with dignity during a medical appointment by raising voice, pointing finger, scolding, shoving (R1) in wheelchair and forcibly pushing wheelchair when (R1) attempted to roll to the front desk. This posed an immediate health and personal rights risk to (R1).	8 9 10 11 12 13 14	Licensee/Administrator to complete a personal rights training by an approved vendor. Submit proof of training documentation to Community Care Licensing by 02/22/21.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Lyndia Sager	TELEPHONE: (805) 680-7683
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2021

LIC9099 (FAS) - (06/04)

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