Carpel Board and Care Facility

Allegation investigated: Staff handled a resident roughly, resulting in injury to the resident.

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced subsequent visit to deliver findings regarding the above-mentioned allegation. LPA identified themselves and met with Licensee Leonor Carmona to discuss the purpose of the visit and elements of the complaint. On 04/02/2026, it was alleged that staff handled a resident roughly, resulting in injury. The department's investigation consisted of interviews and records review. Regarding the allegation, staff consistently reported that the resident(R1) exhibited ongoing combative behaviors, including hitting, spitting, swinging limbs, throwing objects, attempting to leave the facility, and resisting care. Staff stated that when assistance was required for changing or redirection, multiple staff occasionally provided support due to R1's strength and resistance but denied using rough handling. Staff reported no injuries observed on R1. (Cont. on LIC 9099-C) Unsubstantiated (Cont. from LIC 9099) An interview with an outside source (OS1) reported that R1 had a history of making claims that others are “hurting” or “pushing” them when resisting care or direction, including in situations involving OS1 and family members. OS1 further reported that during visits at the hospital after R1's admission, they did not observe any bruising or marks on R1's body. OS1 stated they did not believe facility staff caused harm and described staff interactions observed as consistent with efforts to assist a resident who was rejecting care. Records reviewed indicated that the resident was admitted with diagnoses including dementia and psychotic disturbance and required some assistance with ADLs and mobility. Facility notes documented episodes of restlessness, combative behaviors, and refusal of redirection in the days leading up to hospitalization. No care plan, physician’s report, or MAR could be reviewed; the licensee was cited in a separate visit for incomplete recordkeeping. Based on interviews and records review, the preponderance of evidence standard has not been met, therefore the above allegation is found to be unsubstantiated. An exit interview was conducted with Licensee Leonor Carmona and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided. Their signature confirms receipts of these documents.the state’s words, verbatim · CDSS document, May 15, 2026 · control 08-AS-20260402085610

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Janet Ngallo conducted a Case Management - Deficiencies visit. LPA was greeted and allowed entry into the facility by Staff, Soledad Suba. Licensee Leonor Carmona joined the visit shortly after. Today, LPA was at the facility regarding a complaint investigation and observed a deficiency. LPA requested resident records for Resident #1 (R1) and was made aware by the licensee that the files were incomplete. The licensee stated that the resident was admitted to the facility without the required documentation. The licensee did not obtain a medical assessment, pre-admission appraisal, resident appraisal, functional capabilities, mental condition, or social factors assessment for R1. LPA explained the importance on required documentation for admittance. One deficiency was observed and cited on the attached LIC 809D. A plan of correction was jointly developed with the licensee. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Licensee Leonor Carmona whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Apr 3, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: May 1, 2026

(a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not maintain records for R1, a former resident, which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 3, 2026

Plan of correction: Due to R1 no longer being a resident, the licensee agreed to attend training on resident records and provide proof of training with training topic clearly noted and signatures of attendees by POC due date.

Allegation investigated: Staff inappropriately restrained resident.

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced visit to initiate a complaint investigation and deliver findings regarding the above mentioned allegation. LPA identified themselves and met with Licensee Leonor Carmona to discuss the purpose of the visit and elements of the complaint. On 02/06/2026, it was alleged that staff inappropriately restrained a resident. The department's investigation consisted of interviews, records review, and observations. (Cont. on LIC 9099-C) Substantiated (Cont. from LIC 9099) Interviews with staff corroborated the allegation. By admission, staff reported that a fabric tie was used to secure Resident 1 (R1) in a wheelchair to prevent them from falling forward. Staff reported that the resident was unable to release the tie independently. Staff stated that the restraint was applied periodically when the resident was seated in the wheelchair and staff were not present to monitor R1 in the living room area. Staff confirmed that the restraint was removed after being advised by a social worker that its use was not permitted. LPA reviewed R1’s physician report and hospice records. No physician order was found authorizing the use of any postural support for R1. Hospice records revealed that R1 is bed-bound and wheelchair bound, requires one person assistance for transfers, and has upper extremity stiffness. Hospice documentation also noted that caregivers are to receive instruction on fall precautions and safe use of assistive devices. LPA observed the fabric tie used to secure R1, observed as a scarf-like cloth. Staff demonstrated how the tie was applied around the resident’s lower torso to hold R1's posture in the wheelchair. LPA observed R1 in bed, clean, well-groomed and asleep. Staff showed LPA the wheelchair used by R1 but did not apply the restraint to R1 for demonstration during the visit due to R1 being asleep. Based on observations, interviews and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Licensee Leonor Carmona, whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Feb 11, 2026 · control 08-AS-20260206143548

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a) · Plan of correction due date: Mar 6, 2026

(a)Based on the individual's preadmission appraisal… Postural supports may be used under the following conditions. This requirement was not met, as evidenced by: Based on observations, records review and interviews, licensee did not follow postural support conditions for One(1) out of (Four)4 residents. This posed a potential health and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Feb 11, 2026

Plan of correction: The Licensee will conduct in-service postural support training with all facility staff and provide a sign-in sheet with signatures and training topic clearly noted to LPA via email by 03/06/2026.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Adminstrator Leonor Carmona. According to the facility’s license, the facility has a maximum capacity of six (6) residents, all of whom may be non-ambulatory. Hospice waiver for two(2) residents granted. LPA Ngallo, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Residents bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and residents activities. Hot water temperatures were compliant at 112 F in all bathrooms used by residents. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to residents. Medications were labeled, as required, and stored in locked areas. (Cont. LIC 809-C) No pools or bodies of water on the premises. Per Administrator, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and reviewed multiple staff and client records/files. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Administrator Leonor Carmona to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Dec 8, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Licensee Leonor Carmona. According to the facility’s license, the facility has a maximum capacity of 6 residents, of whom all may be non-ambulatory. During today’s inspection, there were a total of five (5) residents in care. This facility does not feature a secured perimeter or delayed egress doors. LPA, accompanied by Leonor Carmona, toured the interior and exterior of the facility. Pathways were free of obstruction and slip hazards. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Hot water temperature at taps accessible to clients were all compliant. There was at least 2 days supply of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters observed available to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water were observed on the premises. Per Leonor Carmona, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. (CONTINUED ON LIC809-C) (CONTINUED FROM LIC809) Confidential records were stored in locked areas. Leonor Carmona also presented current/active business liability insurance. An exit interview was conducted with Leonor Carmona, and a copy of this report and Licensee Rights (LIC 9058 01/16) were provided to Leonor Carmona.the state’s words, verbatim · CDSS document, Jan 31, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced visit for a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Licensee Leonor Carmona. During today’s visit, LPA toured the facility and interviewed clients. No deficiencies were cited during today’s visit. Due to time constraints, a return visit on a subsequent day is needed to complete the annual inspection. An exit interview was conducted with Leonor Carmona, and a copy of this report and Licensee Rights (LIC 9058 01/16) were provided to Leonor Carmona.the state’s words, verbatim · CDSS document, Jan 8, 2025

Type of visit: Required - 1 Year

On 1/9/2024, at about 12:10 PM, Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced Required Annual Inspection. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Leonor Carmona, Administrator. According to the facility’s license, the facility serves six (6) elderly residents, age 60 and above, all of whom may be non-ambulatory. Hospice waiver for two (2) residents granted. During the inspection, LPA toured the interior and exterior of the facility and observed each resident’s room. The facility was organized, kempt and in good repair. Pathways inside the property were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. There was at least two days of perishable food, and at least seven days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water were observed on the premises. Per Administrator, Carmona, no firearms or ammunition are kept at the facility. Emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present and serviceable. First aid kit(s) was observed. Required licensing postings were observed in visible areas of the facility. Hot water temperatures measured at 112.4 and 112. 6 in sinks accessible to residents. LPA interviewed residents and reviewed staff and resident records/files. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas. Licensee was given Technical Advisories for carbon monoxide and smoke detectors, CPR/First Aid certification and storing cleaning supplies. No deficiencies were cited during today's annual inspection. An exit interview was conducted with Administrator, Carmona to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jan 9, 2024