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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802469
Report Date: 09/16/2024
Date Signed: 09/16/2024 10:25:21 AM


Document Has Been Signed on 09/16/2024 10:25 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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



FACILITY NAME:CARMEL HOMEFACILITY NUMBER:
565802469
ADMINISTRATOR:FROILAN MONTESFACILITY TYPE:
740
ADDRESS:1090 CARMEL DRTELEPHONE:
(805) 955-0435
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:4CENSUS: 4DATE:
09/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Cristina WilliamsTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced Case Management – Incident visit at 09:30 a.m. for the purpose of investigating self reported incident reports. LPA was joined by Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Ryan Landseadel and Patrick Brown. Upon arrival, LPA and QAS met with Program Director Cristina Williams and explained the reason for the visit.

On 09/02/2024, at approx 11:50am, Staff #1 (S1)  informed program manager Cristina Williams that on the evening of 09/01/2024, Resident #1 (R1) informed  S1 that Staff #2 (S2) allegedly hit R1 on their arm. No discoloration / marks were found on R1's arm.

Today, LPA and QAS conducted physical plant, interviewed staff, clients and reviewed and obtained copies of pertinent documentation relevant to the investigation.

LPA and QAS interviews with four (4) staff and R1 revealed they all have not observed any staff become physically or verbally aggressive with any clients in care. Each person interviewed did not express any immediate or potential concerns for staff becoming physically or verbally aggressive with them at this time. Records review of internal investigation conducted by Program Manager did not reveal any immediate or potential concerns for staff becoming physically or verbally aggressive with residents at this time.

Based on interviews and records review no immediate or potential health and safety concerns were observed during the visit and no deficiencies cited at this time.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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