Carlovy Homes in Carlsbad

Type of visit: Annual/Random

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Caregiver xx. The facility's license shows a maximum capacity of six (6) residents, three (3) of whom may be ambulatory, and three (3) of whom may be non-ambulatory. During today’s inspection there were one (1) residents in care. LPA and Caregiver 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. Client bedrooms contained the required furnishings. Doors, windows, screens, 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 client activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Caregiver Rachel Equino, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. 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. LPA interviewed staff and reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. Caregiver Rachel Equino stated that the facility will be closing at the end of the month. No deficiencies were cited during the inspection. An exit interview was conducted with Caregiver Rachel Equino to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Aug 29, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Hannah Rodgers and Janet Ngallo conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPAs were welcomed by and discussed the purpose of the visit to Head Caregiver Manny Rodriguez. The facility's license shows a maximum capacity of six (6) residents, three (3) of whom may be ambulatory, and three (3) of whom may be non-ambulatory. During today’s inspection there were five (5) residents in care. LPAs and Head Caregiver Manny Rodriguez toured the interior and exterior of the facility, and inspected each room. Pathways were free of obstruction and slip hazards. Residents bedrooms contained the required furnishings. Doors, windows, screens, 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 resident activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. LPAs observed five (5) unlabeled daily medication containers that were filled with residents medications poured in advance in a locked cabinet located in the kitchen. The medications in the daily containers were not in its originally received container and had been transferred from their originally received container. No pools or bodies of water exist on the premises. Per Head Caregiver Manny Rodriguez, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. 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] LPAs reviewed facility records. The files reviewed by LPAs contained required documents. Confidential records were stored in locked areas. One deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A plan of correction was jointly formulated, and an exit interview was conducted with Head Caregiver Rodriguez, to whom a copy of this report, LIC809-C, LIC809-D and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.the state’s words, verbatim · CDSS document, Aug 27, 2025

Allegation investigated: Facility staff locked resident in their bedroom

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Head Caregiver Manny Rodriguez. On April 1, 2025, it was alleged that the facility staff locked a resident in their bedroom. The Department’s investigation consisted of an unannounced facility visit, interviews with facility staff and residents, outside sources, and records review. According to the allegation, Resident #1 (R1) was being locked into their bedroom at night via a locking mechanism that locks the bedroom door from the outside. It was also alleged that R1 was being locked in their bedroom at night due to their wandering behaviors, that were primarily exhibited during the night hours. [Continued on LIC9099-C] Substantiated R1’s physician’s report dated March 12, 2025, confirmed R1 was diagnosed with Alzheimer’s Disease, had sundowning behavior, was unable to follow instructions, and required staff assistance for all activities of daily living (ADLs). R1 was unable to be used a reliable historian to aid in this investigation due to their baseline memory loss. Records review revealed that on April 3, 2025, local law enforcement conducted a visit to the facility during the night hours. Per the police report, a tour of the facility and interviews with staff and residents were conducted. Interviews with staff revealed that the facility staff had installed a lock on R1’s door and was locking R1 into their bedroom, from the outside, during the nighttime hours. Interviews with staff revealed R1’s wandering behaviors are primarily prominent during the night hours. On April 4, 2025, LPA accompanied by staff, toured the interior of the facility and inspected each bedroom. LPA observed R1’s bedroom door with a lock on the doorknob that could be locked from the outside via a key. LPA observed R1 to be unaware of their surroundings. LPA was unable to qualify R1 for interview. Based on direct LPA observations, interviews, and records reviewed, a preponderance of evidence exists to support the allegation. One deficiency is being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Head Caregiver Manny Rodriguez, to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to. Interviews with residents did not reveal any concerns with the staff not providing care while on duty nor did the interviews reveal that resident needs were not being met. Interviews with outside sources revealed that there have been consistently at least two staff members at the facility providing care and supervision. Interviews with outside sources did not reveal the observation of staff sleeping while on duty. Interviews with residents, staff, and outside sources did not reveal that staff members were asleep while they should have been on providing care and supervision. The records reviewed by LPA did not reveal a specified staff ratio requirement for one-on-one continuous care for any residents nor did it reveal a need for additional overnight supervision. Based on interviews and record review, the investigation did not yield a preponderance of evidence to conclude that the facility staff were sleeping while on duty. Based on the foregoing, the allegation is unsubstantiated. This finding means that although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Head Caregiver Manny Rodriguez, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Apr 23, 2025 · control 08-AS-20250401102352

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: May 21, 2025

87468.1(a)(6) Personal Rights of Residents in All Facilities (a) residents… shall have all of the following personal rights (6) … to not be locked in any room, building, or on facility premises by day or night… This requirement has not been met as evidenced by: Based on interviews, records review, and observations the licensee did not comply with the section above in that one (1) out of five (5) residents were locked in their bedroom at night, which posed a potential personal rights risk.the state’s words, verbatim · CDSS document, Apr 23, 2025

Plan of correction: Licensee agrees to remove locking doorknob by the date of 4/24/25 and send the Department proof of removal. Licensee agrees to conduct an in-service training on the personal rights of residents and submit a sign-in sheet and topic agenda to the Department by POC date of 5/21/25.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Head Caregiver Manny Rodriguez. The facility's license shows a maximum capacity of six (6) residents, three (3) of whom may be ambulatory, and three (3) of whom may be non-ambulatory. During today’s inspection there were five (5) residents in care. LPA and Head Caregiver Manny Rodriguez 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. Client bedrooms contained the required furnishings. Doors, windows, screens, 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 client activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Head Caregiver Manny Rodriguez, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. 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. LPA interviewed staff and clients, and reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with Head Caregiver Manny Rodriguez to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, May 17, 2024