Carmel Home

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced Case Management - Incident visit. Upon arrival LPA met with Area Director Cristina Williams and explained the reason for the visit. On 08/18/2026, the Department received a self reported incident report that stated, on the afternoon of 08/18/2026, it was discovered that Resident #1 (R1)'s Docusate Sodium for 08/15/2026 at 08:00 p.m was not administered as prescribed due to staff error. On 09/03/2026, Area Director was notified of a missed dose when it was discovered that on 09/03/2026 Resident #2 (R2)'s Aspirin Low 81MG was not administered as prescribed due to staff error. No side effects or concerns were reported for each instances. At approximately 1:10 p.m., the LPA conducted a physical plant review, interviewed staff, observed the medication verification process, and reviewed and obtained copies of relevant incident documentation.Carmel Home staff will continue using the audible medication alarm, which announces all designated medication passes. Certified medication passers will also continue wearing brightly colored safety vests to indicate that a medication pass is in progress and that they should not be disturbed. All certified medication passers received retraining on medication administration on 09/03/2026. Effective 09/08/2026, a second staff member must verify and document, within 15 minutes of medication administration, that all medications were administered as prescribed. Effective 09/14/2026, staff implemented a shift-change medication checklist to document and track that all medications scheduled during each shift were administered as prescribed. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 809-D). A civil penalty in the amount of $250 was issued for a repeat violation Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted, appeals rights discussed and copy of report issued.the state’s words, verbatim · CDSS document, Sep 22, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 23, 2026

Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above as R1 and R2 were not administered medications as prescribed, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 22, 2026

Plan of correction: Area Director stated staff have been retrained and will continue to follow protocols, with additional measures. Director also agreed to review reg cited and submit a written plan to ensure future compliance then send to LPA by close of business on 09/23/2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. Upon arrival, the LPA met with Area Director Cristina Williams and explained the reason for the visit. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. LPA inspected the kitchen/food service area at approx. 10:00 a.m. Knives and sharp objects are stored in a locked drawer left of the sink. Some cleaning supplies were observed stored inaccessible underneath the sink. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food properly stored at this time. Medication area was located next to the kitchen, medication and resident files were observed stored inaccessible to residents in care. At the time of the visit, the common area furniture's were observed to be in good condition. The facility maintained a comfortable temperature of 72 degrees Fahrenheit. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. LPA observed fire extinguishers to be fully charged and last serviced 02/2026. LPA observed four(4) resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in each restroom between 105 - 120 degrees Fahrenheit. LPA observed hallway cabinets to store extra supply of linen. All exits have functioning auditory devices and were operational at the time of the visit. The LPA observed required postings throughout the common areas. There is an attached garage observed inaccessible to residents in care. LPA observed garage to store emergency food and emergency supplies. LPA also observed a laundry area, a sufficient supply cleaning supplies securely stored, extra incontinent supplies, PPE , as well as additional furniture and medical equipment for facility use. The backyard has a covered outdoor area equipped with furniture including a table and chairs for resident use. The LPA observed one (1) self-latching gate with clear passageways clear of obstruction. There were no bodies of water over 3ft noted at the time of the visit. Records review, four (4) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Six (6) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were observed to be in order at this time. Cash resources were reviewed for resident in care. All cash resources were documented appropriately and accurately and were accompanied by corresponding receipts. No deficiencies were observed during cash resource review. Medication review, medications for all residents were observed. All medications were stored properly and were appropriately documented electronically on the facilities Quick Mar Program. No deficiencies were observed during medication review. Cash resources were reviewed for clients in care. All cash resources were documented appropriately and accurately and were accompanied by corresponding purchase receipts. No deficiencies were observed during cash resource review. Infection control / Emergency Disaster plan: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are to be conducted quarterly; the facility’s last emergency disaster drill was conducted on 05/18/2026. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s administrator. Smoke detectors and carbon monoxide detectors were tested, all alarms were functional at the time of the visit. During today’s visit LPA obtained a copy of the facility’s LIC 500, Limited Liability and resident roster. Exit interview conducted and copy of the report was issued.the state’s words, verbatim · CDSS document, Jun 15, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced Case Management - Incident visit. Upon arrival LPA met with Cristina Williams and explained the reason for the visit. On 04/06/2026 and 04/17/2026 the Department received two (2) separate self reported incident reports for missed medications for Client #1 (C1) and Client #2 (C2). On 04/02/2026, it was discovered C1's evening dosage of Lorazapam for 04/01/2026 was not administered. On 04/15/2026, it was discovered C2's afternoon dosage of Olanzapine was not administered on 04/14/2026. No side effects or concerns were reported for each instances. Two (2) staff were retrained and are back to passing medications. At approx 11:26 p.m. LPA conducted physical plant, interviewed staff as well as reviewed and obtained copies of pertinent documentation relevant to the incident. The Administrator stated that they will continue to follow their protocol requiring one medication passer to observe another during medication administration to ensure proper oversight. In addition, the Administrator will require medication passers to wear a brightly colored vest to signal to other staff that they should not be interrupted, allowing them to focus on administering medications safely. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 809-D). Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted, appeals rights discussed and copy of report issued.the state’s words, verbatim · CDSS document, Apr 23, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 24, 2026

Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above as C1 and C2 were not administered medications as prescribed, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 23, 2026

Plan of correction: Administrator stated staff have been retrained and will continue to follow protocols, with additional measures. Administrator also agreed to review reg cited and submit a written plan to ensure future compliance then send to LPA by close of business on 04/24/2026

Allegation investigated: Staff spoke to resident in an inappropriate manner.

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent complaint visit to investigate the allegation listed above. Upon arrival LPA met with Cristina Williams and explained the reason for the visit. On 11/17/2026, LPA Martha Arroyo initiated the 10-day visit between approx. 03:00 p.m. - 04:00 p.m. LPA Arroyo conducted an interview with the Administrator Assistant, conducted a file review, and obtained copies of pertinent documents relevant to the investigation. On 02/12/2026, between approx. 02:00 p.m. to 03:00 pm, LPA Balisi conducted a subsequent complaint visit. During the visit, LPA conducted physical plant tour, interviewed staff, residents and reviewed and obtained copies of pertinent documentation relevant to the investigation. On 02/19/2026, LPA interviewed Tri-Counties Regional Center Quality Assurance Specialist (QAS) Patrick Brown. It was reported that "Staff spoke to resident in an inappropriate manner" as it was alleged that Staff #1 (S1) said the following to Resident #1 (R1), "Why are you so fat?". Unsubstantiated Interviews and record review reflected that on 11/14/2025, S1 was assisting R1 in the restroom and was overheard stating, “Why are you so big?” Four (4) staff members were interviewed. Two (2) staff reported they have never observed staff speak inappropriately to any residents. One (1) staff member who was aware of the incident believed the comment was inappropriate. Another staff member who was aware of the incident stated the comment did not appear to be directed at R1 but rather was said aloud as a general remark. R1 was checked following the incident. Due to hearing impairment, R1 did not indicate awareness that any inappropriate comment had been made. An internal investigation was conducted from 11/17 to 11/19/2025 and included interviews with four (4) staff members and R1.The investigation found insufficient evidence to substantiate that S1 was verbally abusive toward R1.The evidence indicated that the comment regarding weight was made to a co-worker and not directed at R1. Per interview with S1, the comment “heavy” was stated because usually R1 assist with their mobility however, during the time R1 was not being supported by any device therefore, making the transfer “heavy” than usual. R1 did not demonstrate awareness of the comment or any resulting harm. LPA reviewed the internal investigation findings with Quality Assurance Specialist (QAS) Brown, who agreed the comment did not appear to be directed at R1 and that R1 showed no awareness of or harm from the remark. Furthermore, Brown did not express any concerns for staff saying anything inappropriate to any residents at this time. LPA attempted to interview R1, but LPA was not able to successfully communicate with R1 during the investigation. Based on the information obtained during the investigation, even though S1 made a remark regarding R1’s weight it was not intended to be negative and misconstrued due to language barrier. S1 was remorseful of the situation and agreed to additional training. Therefore, the above allegation “Staff spoke to resident in an inappropriate manner” is deemed UNSUBSTANTIATED at this time. Exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, Mar 4, 2026 · control 29-AS-20251116161517

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. Upon arrival, the LPA met with Administrator Assistant Saif Ali and explained the reason for the visit. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. LPA inspected the kitchen/food service area at approx. 10:00 a.m. Knives and sharp objects are stored in a locked drawer left of the sink. Some cleaning supplies were observed stored inaccessible underneath the sink. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food properly stored at this time. Medication room was located next to the kitchen, medication and resident files were observed stored inaccessible to residents in care. At the time of the visit, the common area furniture's were observed to be in good condition. The facility maintained a comfortable temperature of 72 degrees Fahrenheit. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. LPA observed fire extinguishers to be fully charged and last serviced 02/05/2025. The LPA observed four(4) resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in each restroom between 105 - 120 degrees Fahrenheit. LPA observed hallway cabinets to store extra supply of linen. All exits have functioning auditory devices and were operational at the time of the visit. The LPA observed required postings throughout the common areas. There is an attached garage observed inaccessible to residents in care. LPA observed garage to store emergency food and emergency supplies. LPA also observed a laundry area, a sufficient supply cleaning supplies securely stored, extra incontinent supplies, PPE , as well as additional furniture and medical equipment for facility use. The backyard has a covered outdoor area equipped with furniture including a table and chairs for resident use. The LPA observed one (1) self-latching gate with clear passageways clear of obstruction. There were no bodies of water over 3ft noted at the time of the visit. Records review, four (4) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Six (6) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were observed to be in order at this time . Last emergency disaster drill was conducted on May 30th , 2025. Medications review, medications are centrally stored in a locked cabinet adjacent to the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. PRNs have physicians order on file. Medications are properly documented on the centrally stored medications and destruction record. Medications appeared to be given as prescribed at the time of the visit. Infection control: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of a communicable disease. The facility has an adequate supply of Personal Protection Equipment (PPE), and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of an infectious disease. The facility’s policies and procedures as it pertains to infection control are adequate. The LPA obtained the following documents at the time of visit: LIC500 Personnel Report, LIC9020 Client Roster, a copy of the emergency disaster plan, and a copy of the facility’s liability insurance. Interviews were conducted during the visit. Exit interview conducted. A copy of the report was provided to the Administratorthe state’s words, verbatim · CDSS document, Jun 5, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced Case Management - Incident visit. Upon arrival LPA met with Cristina Williams and explained the reason for the visit. On 03/25/2025, 03/31/2025 and 04/01/2025 the Department received three (3) separate self reported incident reports for missed medications for Client #1 (C1) and Client #2 (C2). On 03/24/2025, it was discovered C1 was not passed their medication on the morning of 03/23/2025. On 03/30/2025, it was discovered C2 was not passed their medication on the morning of 03/28/2025. On 04/01/2025, it was discovered C2 was not passed their AM medication. No side effects or concerns were reported for each instances. Two (2) out of the three (3) staff were retrained. The third staff is in process of re-training at this time. At approx - 01:15 p.m. LPA conducted physical plant, interviewed staff, observed staff passing out medication with new medication administration protocol. LPA also reviewed and obtained copies of pertinent documentation relevant to the investigation. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 809-D). Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted, appeals rights discussed and copy of report issued.the state’s words, verbatim · CDSS document, Apr 7, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 8, 2025

Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above as C1 and C2 were not administered medications as prescribed, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 7, 2025

Plan of correction: Administrator stated staff have been retrained and they have implemented new protocols to ensure future compliance. Administrator agreed to review regulation cited and provide a statement of understanding to LPA via email by 04/08/2025 COB.

Type of visit: Case Management - Incident

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.the state’s words, verbatim · CDSS document, Sep 16, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced for a required one-year annual inspection today. The last annual conducted at this facility was on 06/05/2023. When the LPA arrived, there were three (3) staff and three (3) residents present. The LPA met with Program Manager, Cristina Williams, and at this time the reason for the visit was explained. Entrance interview. At 9:01 a.m., the LPA along with the Program Manager toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: The LPA inspected the kitchen/food service area at 9:18 a.m. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Food labels were inspected and checked for dates and expiration dates. The knives and sharps were observed in a locked drawer inaccessible to residents in care. Cleaning solutions were observed locked and inaccessible under the kitchen sink. At 9:20 a.m., the hot water temperature was measured in the kitchen sink, and it measured 110.8 degrees Fahrenheit. COMMON AREAS: At the time of the visit, the living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. The smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguishers were observed to be fully charged on 02/16/2024. Continued on LIC 809C... Continued from LIC 809... LPA observed required postings throughout the common space. There is a working telephone on premises. Working auditory alarms were observed at the time of the visit. Different activities for resident use were observed by the living room. There is a closet by the hallway designated with additional activities for residents. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. GARAGE: The garage is attached and inaccessible to residents in care. The facility has a sufficient amount of emergency food and water. LPA observed a sufficient supply of Personal Protection Equipment (PPE). The washer and dryer were observed inside the garage. Detergents and cleaning solutions were observed in the garage locked and inaccessible at the time of the visit. BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. Emergency exits and passageways were observed free of obstruction. There was one (1) gate that self-latches. No bodies of water were noted at the time of the visit. BEDROOMS: There are four (4) resident bedrooms. LPA observed the resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. LPA observed additional clean linens and towels in a hallway closet for resident use. RESTROOMS: There are two (2) restrooms designated for resident use. Restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. The hot water temperature was measured in both bathrooms. The first bathroom measured 109.4 degrees Fahrenheit at 9:05 a.m.; and the second bathroom measured 106.3 degrees Fahrenheit at 9:11 a.m. Continued on LIC 809C... Continued from LIC 809C... RECORDS: Records review began at 9:35 a.m.; four (4) resident records were reviewed for, but not limited to: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, and current needs and services plan/individual program plan. All records were complete. Three (3) personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were complete. The facility is vendored by Tri-Counties Regional Center (TCRC). The last disaster drill was conducted on 05/22/2024. During today’s visit, LPA obtained copies of the Personnel Report LIC 500, Client Roster LIC 9020, and Certificate of Liability Insurance. MEDICATIONS: Medications review began at approximately 12:45 p.m.; medications are centrally stored by the nurse’s station in a locked cabinet. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications appeared to be given as prescribed at the time of the visit. Exit interview. Report was reviewed and a copy was provided.the state’s words, verbatim · CDSS document, Jun 3, 2024