Carroll's Residential Care

Allegation investigated: Staff did not provide adequate supervision resulting in resident eloping from facility.

Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced visit to open the above complaint allegation. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Pam Pineiro, Admissions Coordinator. Sarita Mendoza, House Manager arrived during the visit. The complainant alleged the staff did not provide adequate supervision resulting in resident eloping from facility. Resident #1 (R1) [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] During the course of the investigation, LPA Holmes conducted a tour of the facility, welfare check on residents in care, reviewed pertinent client care records, and personnel records. and conducted interviews. Interviews revealed that on August 20, 2026 R1 left the facility before dinner. Interviews revealed that on that day R1 took their morning medications at 7:15 am, took their noon medications at 11 am and missed dinner medications at 4:15 pm and their bedtime medications at 7:15 pm. Interviews revealed that R1 is med- complaint. Interviews and observations of R1’s appraisal/ needs and service plan from January 10, 2018 reports that R1 has a history of AWOLing. Unsubstantiated According to R1's physicians report dated January 24, 2018 it states that the resident is not confused or disoriented, it states that R1 does not have wandering behavior, that R1 is able to communicate needs and that they are able to leave the facility unassisted. Interviews revealed there is no record of anyone bringing R1 back to the facility on or around August 18, 2026. Interviews did reveal that on August 20, 2026 R1 left the facility and did not return. The facility completed and filed a missing persons report with the El Cajon Police Department on August 21, 2026. They received a case number from the police department. Upon observation it was observed that the facility staff are following their absentee notification plan. Interviews revealed that on August 23, 2026 R1s primary care doctor informed the facility that R1 was at the hospital. The staff removed R1 from the missing persons system. Interviews revealed that R1 is still at the hospital as of this visit. Interviews revealed they have 19 staff daily with 15 that work directly with the residents and that all staff have been trained on care and supervision and the last training was on August 14, 2026. The staff follow protocol on supervising the residents. Interviews with staff denied not supervising the residents. Based on records, and interviews, a preponderance of evidence does not exist to show the staff did not provide adequate supervision resulting in resident eloping from facility. Therefore, the allegation is Unsubstantiated, meaning the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Sarita Mendoza, House Manager, 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 27, 2026 · control 08-AS-20260818085329

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted a virtual Case Management Visit via telephone conference. The purpose of the visit was discussed with Office Manager Sarita Mendoza. During the visit, LPA discussed the POC due on 8-14-2026. Office Manager, Sarita Mendoza indicated that the POC is complete and that proof of correction will be submitted to CCL by due date. During the visit, LPA issued an amended LIC 9099D to correct the regulatory citation previously delivered on July 13, 2026. The amendment updates the citation reference from Title 22, Division 6, Chapter 6 (Adult Residential Facility) to the correct regulatory authority, Title 22, Division 6, Chapter 8 (Residential Care Facility for the Elderly). The Plan of Correction (POC) due date remains August 14, 2026, and no changes were made to the corrective action requirements. An exit interview was conducted virtually with Office Manager Mendoza on August 11, 2026. Copies of this Case Management report, the amended LIC 9099D, and the Licensee/Appeal Rights (LIC 9058) were provided electronically to Office Manager Sarita Mendoza at the email address on file.the state’s words, verbatim · CDSS document, Aug 11, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA Domingo was welcomed by, identified herself to, and discussed the purpose of the visit with Assistant Manager, Sarita Mendoza The facility fire clearance was granted on 05/02/2023 and reflects that the facility was approved for 144 residents in total, of which 134 may be non-ambulatory, and 10 may be bedridden. The facility's fire clearance did not include endorsements for delayed egress doors or secured perimeter, and neither were present during today's visit. The submitted facility sketch was consistent with the current layout of the facility. During today’s inspection, there were a total of 124 clients in care, and per medical records, all were ambulatory. LPA, accompanied by licensee’s staff, toured the interior and exterior of the facility, and inspected multiple rooms. 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 and 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. Call box was available in each resident unit and were tested for functionality. Resident's room temperatures were within a comfortable range. The facility’s ambient internal temperature was 79 F. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 118 F, Bathroom #1 sink was 118 F, and Bathroom #2 sink was 118 F. Refrigerator temperature was 35 F and freezer temperature was -5 F. 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 sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. [CONTINUED ON LIC 809C] [CONTINUED FROM LIC 809] No pools or bodies of water were observed on the premises. Per the licensee's staff, 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. The last disaster/fire drill was conducted in May 22, 2026 next drill will be August 14, 2026 LPAs interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. The reviewed files 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 Sarita Mendoza, Assistant Manager, 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, Jul 18, 2026

Allegation investigated: Staff did not ensure residents rooms were free of pest

Licensing Program Analyst (LPA) Marisela Garcia Centeno conducted an unannounced visit to deliver investigative findings. LPA met with Office Manager, Sarita Mendoza, and discussed the results of the investigation. The Department investigated the above listed complaint allegation. The investigation consisted of a facility inspection, observations, multiple interviews with residents and staff, interviews with outside sources including the pest control technician and pest control service manager, and a review of relevant records, invoices, and service reports. On July 6, 2026, Community Care Licensing (CCL) received a complaint alleging that staff did not ensure residents’ rooms were free of pests. It was specifically alleged that during a visit on July 3, 2026, at 8:25 p.m., Resident 1 (R1) had an active cockroach infestation in their room, including juvenile and adult roaches of multiple sizes. (continue at LIC9099C) Substantiated (continue from LIC9099) During an in person interview, R1 stated that they routinely observe cockroaches in their room at night when they wake up and turn the lights on. Multiple interviews with housekeeping staff confirmed they frequently observe cockroaches in resident rooms. Staff reported that they attempt to address pest sightings by spraying pesticide chemicals from cans kept on their housekeeping carts. Staff stated they use this on the spot treatment when residents report pest activity. Interviews with facility management indicated that, despite efforts to clean and declutter rooms, residents often bring food and beverages into their rooms and leave them behind. Management acknowledged that this practice contributes to attracting cockroaches. A review of the past six months of pest control service reports and invoices showed the pest control company provides monthly service. Standard service includes spraying common areas such as the kitchen, laundry room, and ten resident rooms selected based on reported pest activity. Service reports repeatedly documented recommendations to seal holes and cracks behind toilets in resident bathrooms as a preventive measure to reduce or control infestations. Records also showed ongoing recommendations to repair loose tiles and address excessive moisture in the kitchen, laundry room, and other areas of the facility. Interviews with outside sources tdisclosed that these recommendations have been communicated to facility management for over a year without corrective action. Both outside sources reported that the facility has not repaired the holes, cracks, or loose tiles, and that the persistent moisture conditions continue to contribute to cockroach activity. Outside sources also recommended upgrading pest control service frequency beyond once per month due to the level of pest activity, but stated the facility has not implemented that recommendation. (continue at LIC9099C) (Continue from LIC 9099C) Multiple resident interviews further confirmed ongoing cockroach sightings, particularly at night or early in the morning when residents wake up to use the restroom. Based on interviews with residents, staff, and outside sources, review of service reports and invoices, and direct observations, the Department determined that there is sufficient evidence to corroborate the allegation. Therefore, the allegation is substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. A deficiency was cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on LIC 9099 D. A Plan of Correction was developed with facility staff during the visit. A copy of this report, LIC 9099 D, and Licensee/Appeal Rights (LIC 9058 03/22) was provided to Office Manager, Sarita Mendoza, at the end of the visit.the state’s words, verbatim · CDSS document, Jul 13, 2026 · control 08-AS-20260706083630

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Aug 14, 2026

87303(a) Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidence by: Based on interviews and records review, the license did not take proper measures to prevent, minimize and control pest infestation. This posed a healthy and personal rights risk to 125 residents in care.the state’s words, verbatim · CDSS document, Jul 13, 2026

Plan of correction: Facility administrator agreed to evaluate the pest control maintenance agreement currently in existance to determine appropriatness. Administrtor agreed to review pest control recommendations and take appropriate actions. Documentation will be submitted to CCL by POC deadline.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Marisela Garcia‑Centeno conducted an unannounced case management visit to follow up on an incident reported to Community Care Licensing (CCL) regarding a fire in the facility’s kitchen. Emergency personnel responded to the incident. During the visit, based on observation and staff interviews it was confirmed that the facility followed proper emergency protocol and implemented its emergency plan. Interviews with staff disclosed that the fire occurred while staff were cooking scrambled eggs on the stove. The fire did not cause structural damage to the facility. No injuries were reported, and utilities were restored within one hour. Residents were not affected by the incident, and breakfast and lunch were provided as required to meet residents’ needs. Facility staff properly reported the incident to CCL on 7/13/2026. Based on observations and interviews during today’s visit: • Staff immediately responded to the fire by using the fire extinguisher and calling 911. • Emergency personnel arrived on site and fully extinguished the fire. • Staff have procured a replacement stove, which will be delivered to ensure continuity of food service for residents. No violations were cited during today’s visit. (continue at LIC809C) (Continue from LIC809) Although no deficiencies were issued, the facility administrator will be following up with the sprinkler system contractor and providing additional staff training to ensure proper implementation of the manual sprinkler protocol. An exit interview was conducted with Manager Sarita Mendoza, who was provided a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22).the state’s words, verbatim · CDSS document, Jul 13, 2026

Allegation investigated: Staff did not prevent resident from engaging in a physical altercation with another resident

Licensing Program Analyst (LPA) Renita Hall conducted an unannounced visit to open a complaint and delivered findings. The Assistant Manager allowed LPA entry. LPA identified herself and disclosed the purpose of the visit and elements of the complaint to the Assistant Manager. Licensing Program Analyst (LPA) conducted interviews, reviewed records, and completed a facility tour in response to the allegation that staff did not prevent a resident from engaging in a physical altercation with another resident. On May 8, 2026, the Department received a complaint regarding the above allegation. On May 12, 2026, during the investigation, LPA interviewed facility staff and involved residents. Staff interviewed stated that Resident 1 (R1) and Resident 2 (R2) are generally friends; however, R2 has difficulty accepting limits and does not respond well when told “no” or when unable to get what they want. R1 reported that R2 punched them in the ear, and in response, R1 punched R2 in the nose. R1 stated that the incident occurred over a month ago and that they and R2 are now friends, with no additional incidents occurring since that time. Unsubstantiated R1 also expressed uncertainty as to why the matter was being reported, as the altercation was not recent and the issue had been resolved between them. R2 confirmed that they struck R1 in the ear and that R1 punched them in the nose during the incident. R2 also stated that they and R1 are now friends and reported no further conflict between them. Staff reported that following the incident, R2’s medication was adjusted and there have been no additional behavioral incidents involving R2. Staff stated that facility protocol is to notify residents’ case managers and psychiatrists when behavioral concerns become a pattern. Staff 2 (S2) confirmed that R2’s case manager was informed of the incident when it occurred and stated there have been no additional altercations between R1 and R2 since that time. LPA reviewed facility records, which confirmed incident reports were completed and documented on April 8, 2026, and April 28, 2026. Documentation reviewed indicated that the facility addressed the incident appropriately and that no further physical altercations between the residents have been reported. Based on interviews conducted, records reviewed, and information obtained during the investigation, there is insufficient evidence to support the allegation that staff failed to prevent a resident from engaging in a physical altercation with another resident. Although an altercation did occur, evidence indicates the facility responded appropriately, addressed the incident, and implemented interventions to prevent recurrence. Therefore, the allegation that staff did not prevent resident from engaging in a physical altercation with another resident is deemed Unsubstantiated. An unsubstantiated finding means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with the Assistant Manager. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Assistant Manager and her signature on this report confirms receipt.the state’s words, verbatim · CDSS document, May 12, 2026 · control 08-AS-20260508141013

Allegation investigated: Staff are not meeting resident's dental needs Staff did not seek timely medical care for resident Staff are withholding resident's money

Licensing Program Analyst (LPA) Renita Hall conducted an unannounced visit to deliver findings regarding the above-mentioned allegations. LPA was allowed entry by the Assistant Manager. LPA identified herself and disclosed the purpose of the visit and elements of the complaint to the Assistant Manager. On March 2, 2026 the Department received a complaint alleging that: Staff are not meeting resident's dental needs, Staff did not seek timely medical care for resident, Staff are withholding resident's money. LPA conducted interviews and reviewed records regarding allegations. Regarding medical care, staff reported that Resident 1’s (R1) case manager is responsible for coordinating medical appointments and transportation. Information obtained indicates that R1 had previously been hospitalized, and there was no evidence of any untreated or ongoing medical condition requiring immediate follow-up care. Continued on 9099C Unsubstantiated The facility reported that in the absence of a responsible party, staff will assist with transportation. The facility operates as a board and care, where residents are ambulatory, independent with activities of daily living (ADLs), and able to leave the facility freely. The facility provides medication management within its scope. LPA attempted to contact R1’s case manager but did not receive a response. There is no evidence that staff failed to seek or delayed necessary medical care. Regarding dental care, documentation shows that on 02/11/2026, staff submitted a referral to R1’s case manager requesting assistance in establishing a dental provider and scheduling an appointment, as R1 does not have an established dentist. R1 confirmed they are waiting to be seen by a dentist. Delays appear related to coordination with the case manager and lack of established providers, not due to inaction by facility staff. Regarding financial management, documentation from the designated payee indicates that R1 independently cashes their Personal and Incidental (P&I) funds in the amount of $100 twice per month. R1 confirmed receipt and use of these funds. R2 stated that they assist R1 with transportation and occasionally provide money when R1 spends their funds. R1 confirmed this and expressed that their monthly funds are insufficient. There is no evidence that facility staff are withholding R1’s money. Additional information obtained indicates that R1 requires identification documents, including a state ID and Social Security card, which are reportedly maintained by the case manager. Staff and R2 indicated that efforts have been made to assist R1; however, lack of access to these documents may be contributing to delays in accessing services such as dental care. On April 29, 2026, LPA verified that R1 has a dental appointment scheduled for June 2, 2026. Based on interviews conducted and records reviewed, the allegations that staff did not seek timely medical care, failed to meet dental needs, and withheld resident funds are unsubstantiated. An unsubstantiated finding means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report along with the Licensee Rights (LIC 9058) was provided to Assistant Manager. Her signature on this form confirms receipt of the documents.the state’s words, verbatim · CDSS document, Apr 29, 2026 · control 08-AS-20260302141339

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Hannah Rodgers and Ramin Hashemi conducted an unannounced case management visit to conduct follow up regarding a self-reported incident of Resident #1 (R1) passing away on August 31, 2025 [See LIC811 Confidential Name List for identification of select person identifiers used in this report]. LPAs were greeted by, identified themselves to, and explained the purpose of the visit with Manager Sarita Mendoza. On September 2, 2025, the Department received an self-reported incident report that described that on August 31, 2025, R1 was found unresponsive and later pronounced deceased. During today’s visit, LPAs conducted a health and safety check, observed residents in care, and reviewed facility records. There were no deficiencies cited during today's visit. However, this incident may require further follow-up visits. An exit interview was conducted with Manager Sarita Mendoza, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to. .the state’s words, verbatim · CDSS document, Sep 3, 2025

Type of visit: Required - 1 Year

This is an unannounced, required annual visit. LPA arrived at the facility and was greeted by staff. The purpose of the visit was explained, and a tour of the facility was conducted. LPA toured the interior and exterior of the facility. The facility was observed to be clean and under remodeling. Common areas and resident rooms were properly furnished, well-lit, and maintained at a comfortable temperature. Hot water is measured between 105°F and 120°F. The facility has a sufficient supply of perishable and non-perishable food items. Medications are stored in a locked medication room inaccessible to residents. All outdoor and indoor passageways were free from obstruction. Required postings were observed, including the Complaint Poster, Emergency Disaster Plan, Personal Rights, and License. LPA reviewed a sample of resident and staff records. Files were complete and contained all required documentation. Staff have current First Aid/CPR certifications and have criminal record clearances. Medications were reviewed and observed to be properly labeled and administered according to the physician’s orders. LPA observed a fire extinguisher with a current service tag. Smoke detectors and carbon monoxide detectors were tested and operational. The facility maintains an emergency disaster plan. LPA conducted interviews with 5 staff members and 4 residents. No concerns were expressed during the visit. No citations issued. An exit interview was conducted with the Administrator. No deficiencies were observed during today’s visit. A copy of the report was provided along with the Licensee Rights (LIC 9058), was provided to the Administrator. His signature on this form confirms receipt of the documents.the state’s words, verbatim · CDSS document, Jul 21, 2025

Allegation investigated: Staff are financially abusing client in care Facility is failing to meet the needs of client

Licensing Program Analysts (LPA) Angelica Boyles conducted an unannounced visit to deliver investigative findings regarding the above-mentioned allegations. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Assistant Administrator Sarita Mendoza. The Department’s investigation consisted of interviews with staff, residents, and outside sources, records review of relevant documents pertinent to this investigation, and LPA observations. On January 14, 2025, it was alleged that the facility staff were financially abusing Resident #1 (R1) [See LIC811 Confidential Name List for a description of select person identifiers used in this report] and facility staff were failing to meet R1's needs. (Continued on 9099C) Unsubstantiated Regarding the allegation of financial abuse, LPA interview with R1 did not corroborate this allegation. R1 did confirm going to the bank with facility staff once, but reported it was to change mailing address after moving to the facility. LPA interview with staff aligned with R1's report of visiting the bank. Regarding the allegation of R1's needs not being met, LPA did not observe R1 to be in soiled clothing or smelling bad. LPA observations did not indicate that resident's needs were not being met. While records reviewed did indicate R1 might require occasional minor assistance, R1 reported being fully independent and not requiring staff assistance with activities of daily living. R1 reported being comfortable asking for help if and when needed. Further, LPA interview of an outside source familiar with the facility did not express any concerns regarding both above mentioned allegations. The Department has investigated the allegations that staff are financially abusing client in care and facility is failing to meet the needs of client. Based upon the information obtained during this investigation, it is determined that the preponderance of evidence was not met to support or corroborate these allegations and therefore deemed unsubstantiated. The report was discussed, and an exit interview was conducted with Assistant Administrator Sarita Mendoza. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided at the conclusion of the visit. The signature below confirms the receipt of these documents.the state’s words, verbatim · CDSS document, Apr 23, 2025 · control 08-AS-20250114160512

Allegation investigated: Staff did not ensure residents were seen by a physician Staff are threatening resident

Licensing Program Analyst (LPA) Renita Hall, conducted an unannounced visit regarding the above-mentioned allegations. LPA was allowed entry by Brian Meyers, Administrator. LPA identified herself and disclosed the purpose of the visit and elements of the complaint with the Administrator and delivered findings. This report is updated for July 29, 2024, when LPA conducted additional interviews. Staff 1 (S1): S1 stated that on the day of the incident, they witnessed Resident 1 (R1) enter a room, visibly upset, and yelling about not seeing a doctor. S1 noted that the Administrator told R1, "Not now, I'm in a meeting, and I'll speak with you when I'm done." R1 continued to express frustration. The Administrator asked R1 to leave, assuring they would discuss the issue later. R1 left the room upset but was calm after the Administrator spoke to them that afternoon. Unsubstantiated Resident 2 (R2): R2 reported no issue with seeing a doctor and did not witness any threats by staff towards residents. R2 acknowledged hearing R1 talk about complaining due to not seeing a physician. R1 did not have a medical need that could required immediate attention from the doctor at the time of the visit. R1 had left the line on multiple occasions which led to them not being seen by the doctor on the day of the incident. Based on the investigation findings, the allegations made against the facility are unsubstantiated. A finding that is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Sarita Mendoza, Administrator Assistant. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Administrator Assistant and her signature on this report confirms receipt of the Licensee Rights.the state’s words, verbatim · CDSS document, Feb 19, 2025 · control 08-AS-20240611143909

Allegation investigated: Staff do not prevent residents from smoking in prohibited areas

Licensing Program Analyst (LPA) Renita Hall, conducted an unannounced visit regarding the above-mentioned allegations. LPA was allowed entry by Sarita Mendoza, Administrator Assistant. LPA identified herself and disclosed the purpose of the visit and elements of the complaint with the Administrator Assistant and delivered findings. The facility has designated areas for smoking with no smoking signs posted in areas not deemed as designated. Observation of the facility did not reveal residents smoking in areas not designated for smoking. The facility policy addressed smoking in designated areas only. On July 29, 2024, while conducting an Annual 1-year Visit. No residents were observed smoking in non-designated areas. Residents were on the second patio away from the dining hall in the designated smoking area. Unsubstantiated One resident who was interviewed stated " I don't smoke, I just have a lighter for some of the residents who don't have a lighter. They smoke in the front of the building in the corner and on the patio in the back. " LPA interviewed additional Residents who all confirmed that sometimes some residents smoke in front of the building, but for the most part, they use the designated smoking patio. They are aware of the areas where smoking is not allowed. "We can smoke on the patio as long as the doors are closed, for those who use oxygen tanks." However, residents do not smoke on the patio by the dining hall. Based on the investigation findings, the allegation made against the facility is unsubstantiated. A finding that is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Sarita Mendoza, Administrator Assistant. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Administrator Assistant and her signature on this report confirms receipt of the Licensee Rights.the state’s words, verbatim · CDSS document, Feb 19, 2025 · control 08-AS-20240607145040

Allegation investigated: Licensee did not keep facility free of insects.

Licensing Program Analyst (LPA) Renita Hall, conducted an unannounced visit regarding the above-mentioned allegation. LPA was allowed entry by Brian Meyers, Administrator. LPA identified herself and disclosed the purpose of the visit and elements of the complaint with Brian Meyers and Sarita Mendoza, Administrative Assistant. The Department investigated the above-listed complaint allegation. The investigation consisted of a tour of the facility, interviews with staff, and residents, and a records review, including other relevant evidence pertinent to this investigation such as the Pest Control maintenance contract agreement and Inspection Reports. On November 4, 2024, Community Care Licensing (CCL) received a complaint alleging that the Licensee did not keep the facility free from insects. The facility has had a service contract with Orkin since 2002 for monthly pest control treatment with previous treatments on September 24, 2024, and October 29, 2024 {Continued on 9099C} Unsubstantiated As of October 29, 2024, Orkin Pest Control provided services to several residents' rooms that included crack and crevice preventative maintenance of German roach activity. On November 13, 2024, LPA’s observation; room inspection revealed no remnant of roaches or other insects. Residents interviewed all stated that they did not have roaches or other insects at the time of the visit. Based on observations, interviews with residents, and a review of pertinent pest control inspection reports, there was insufficient evidence found to support the allegation that the Licensee did not keep the facility free of insects. Due to a lack of evidence, the allegation is deemed to be unsubstantiated. A finding that is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Sarita Mendoza, Administrative Assistant. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Administrative Assistant and her signature on this report confirms receipt of the Licensee Rights.the state’s words, verbatim · CDSS document, Nov 13, 2024 · control 08-AS-20241104154720

Allegation investigated: - Facility failed to safeguard resident belongings

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to deliver investigative findings regarding the above-mentioned allegation. LPA identified herself and was granted entry by Assistant Administrator Sarita Mendoza. LPA stated the purpose of the visit and reviewed the findings of the complaint with Assistant Administrator Mendoza. The Department’s investigation consisted of interviews with staff, residents, and outside sources, records review of relevant documents pertinent to this investigation, and LPA observations. On June 13, 2024, it was alleged that the facility staff failed to safeguard the resident’s belongings. It was specifically alleged that resident #1’s (R1) belongings were being stolen from resident #2 (R2). Interview with resident #1 said that they have missing belongings that resident #2 took from their room. LPA was able to interview residents whose statements conflicted. According to R1, they said R2 stole their cigarettes, lighters, a watch, perfume, scissors, night cream, and money. Unsubstantiated R1 expressed that R2 still enters the room to take their belongings to sell for monetary gain. Interview with R2 said that they have no need to take things from R1 as they do not use any of the items R1 indicates are stolen. R2 said that they have no need to take R1s cigarettes as they do not smoke. Interview with staff said that they have had issues with a resident who contacts the police as they say that another resident steals their belongings, but there is no evidence of the occurrence. Staff mentioned that they have already removed the residents into separate rooms. A review of records revealed that resident had made a police report, but the outcome was that the resident’s belongings were in their possession and that the allegations made were not credible. On June 19, 2024, LPA requested and was granted approval by R1 to go over their belongings that were identified as missing. During the search, LPA observed that within their drawers they did have cigarette lighters, many empty boxes of cigarette’s, a watch, scissors, day/night cream’s, 6 body sprays and old spice, among other items. Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during staff and outside source interviews, records reviewed, and LPA observations, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be unsubstantiated. The report was discussed, and an exit interview was conducted with Assistant Administrator Sarita Mendoza. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Assistant Administrator Mendoza at the conclusion of the visit. The signature below confirms the receipt of these documents.the state’s words, verbatim · CDSS document, Oct 10, 2024 · control 08-AS-20240613144119

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Renita Hall, conducted an unannounced Required 1 year Annual Visit. LPA was allowed entry by Julia Gutierrez, Receptionist. LPA identified herself and disclosed the purpose of the visit with the receptionist and was later joined by Sarita Mendoza, Assistant Manager and Brian Meyers Administrator. Physical Environment: The facility was clean, maintained, and free from any safety hazards. Adequate lighting and ventilation were observed in all areas of the facility. All necessary safety equipment, such as fire extinguishers and emergency exits, were present and in good working condition. The facility's outdoor spaces were properly maintained and accessible to residents. Staffing and Training: The facility had a sufficient number of qualified staff members to meet the needs of the residents. The staff member was observed to be professional, courteous, and knowledgeable in their respective roles. All staff members had completed the required training and certifications per the licensing regulations. Staffing schedules were posted and adhered to, ensuring adequate coverage. Continued {809C} Resident Care and Services: Residents' care plans were reviewed and found to be comprehensive and up-to-date. Medication administration was observed to be in accordance with the facility's policies and procedures. Residents' nutritional needs were met, and the meals provided were nutritious and balanced. Recreational activities and social engagement opportunities were available to residents regularly. Health and Safety: Regular health assessments and monitoring of residents' well-being were conducted by qualified healthcare professionals. Infection control measures were in place and followed by staff members. The facility had established protocols for emergencies and evacuation plans were readily available. Overall, the facility was found to comply with the licensing regulations. An exit interview was conducted with Brian Meyers, Administrator, and a copy of this report and the Licensee Rights (LIC 9058) were provided. His signature on this form confirms receipt of the documents.the state’s words, verbatim · CDSS document, Jul 29, 2024

Allegation investigated: Staff did not ensure residents were seen by a physician Staff are threatening resident

Licensing Program Analyst (LPA) Renita Hall, conducted an unannounced visit regarding the above-mentioned allegations. LPA was allowed entry by Brian Meyers, Administrator. LPA identified herself and disclosed the purpose of the visit and elements of the complaint with the Administrator and delivered findings. On June 12, 2024, the Department investigated the above-listed complaint allegations. The investigation consisted of a tour of the facility and interviews with staff and resident. Resident 1 (R1) admitted that they were at fault for not staying in line to see the physician. R1 also admitted that they were upset when they went into the office to talk to the Administrator who knew nothing about the appointment for seeing the physician. R1 stated they went to calm down and spoke with the Administrator later the same day to resolve the issue. The Administrator was in a meeting when R1 entered the office screaming and using profanity. R1 was told that the disrespect would not be tolerated and goes against facility policy and eviction would be the next step if continued. No eviction notice has been given to R1. Continued on 9099C Unsubstantiated Based on the investigation findings, the allegations made against the facility is unsubstantiated. A finding that is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Brian Meyers, Administrator. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Administrator and his signature on this report confirms receipt of the Licensee Rights.the state’s words, verbatim · CDSS document, Jun 12, 2024 · control 08-AS-20240611143909

Allegation investigated: Staff do not prevent residents from smoking in prohibited areas

Licensing Program Analyst (LPA) Renita Hall, conducted an unannounced visit regarding the above-mentioned allegation. LPA was allowed entry by Brian Meyers, Administrator. LPA identified herself and disclosed the purpose of the visit and elements of the complaint with the Administrator and delivered findings. On June 12, 2024, the Department investigated the above-listed complaint allegation. The investigation consisted of a tour of the facility and interviews with staff and residents. The facility has designated areas for smoking with no smoking signs posted in areas not deemed as designated areas. Observation of the facility did not reveal residents smoking in areas not designated for smoking. Staff and residents interviewed have not seen smoking in areas not deemed smoking. Unsubstantiated Based on the investigation findings, the allegation made against the facility is unsubstantiated. A finding that is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Brian Meyers, Administrator. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Administrator and his signature on this report confirms receipt of the Licensee Rights.the state’s words, verbatim · CDSS document, Jun 12, 2024 · control 08-AS-20240607145040

Allegation investigated: Facility plumbing is in disrepair.

Licensing Program Analyst (LPA) Renita Hall, conducted an unannounced visit to open a complaint and deliver findings regarding the above-mentioned allegation LPA was allowed entry by Sarita Mendoza, Assistant Manager. LPA identified herself and disclosed the purpose of the visit and elements of the findings to the Assistant Manager. On February 26, 2024, a complaint was received by the Department on Carroll's Residential Facility regarding the state of the plumbing in the facility,it claimed that the plumbing was in disrepair. On March 4, 2024, LPA spoke with the complainant who reported maintenance and housekeeping promptly addressed the issue and the plumbing was no longer a concern. Following the repair, complainant expressed satisfaction with the prompt response and resolution of the issue. They indicated that they were no longer concerned about the state of the plumbing in the facility and wished to withdraw their complaint. Continued on 9099C Unsubstantiated Based on the investigation findings, the allegation made against the staff of Carroll's Residential Care regarding the facility plumbing being in disrepair was found to be unsubstantiated as the issue was promptly addressed and resolved. An exit interview was conducted with Sarita Mendoza, Assistant Manager. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Assistant Manager and her signature on this report confirms receipt of the Licensee Rights.the state’s words, verbatim · CDSS document, Mar 5, 2024 · control 08-AS-20240226154315

Allegation investigated: Staff does not ensure residents receive mail correspondence in a timely manner

Licensing Program Analyst (LPA) Renita Hall, conducted an unannounced visit to open a complaint and deliver findings regarding the allegation mentioned above LPA was allowed entry by Bryan Meyers, Administrator. LPA identified herself and disclosed the purpose of the visit and elements of the findings to the Administrator. On February 7, 2024, an allegation was received by the Department that Carroll's Residential Care stated that staff does not ensure residents receive mail correspondence in a timely manner. LPA Hall interviewed the residents and staff members who may have witnessed or had relevant information regarding the incident and conducted a tour of the facility's mailroom. Allegation: Staff does not ensure residents receive mail correspondence in a timely manner. The mailroom had a posted signed of times mail is distributed which are Monday-Friday from 3:00 pm to 3:30 pm. LPA toured the mailroom and there was no evidence that mail had not been delivered to residents timely. The staff stated that if mail is not handed out between the hours stated, an announcement is made via the PA system that mail will be handed out during dinner. Continued on 9099C Unsubstantiated Based on the investigation findings, the allegation made against the staff of Carroll's Residential Care regarding staff does not ensure residents receive mail correspondence in a timely manner is unsubstantiated. A finding that is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Bryan Meyers, Administrator. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Administrator and his signature on this report confirms receipt of the Licensee Rights.the state’s words, verbatim · CDSS document, Feb 13, 2024 · control 08-AS-20240207142842

Allegation investigated: Facility staff did not treat resident with diginity

Licensing Program Analyst (LPA) Renita Hall, conducted an unannounced visit to deliver findings regarding the above-mentioned allegation LPA was allowed entry by Sarita Mendoza, Assistant Manager. LPA identified herself and disclosed the purpose of the visit and elements of the findings to the Assistant Manager. On October 19, 2023, an allegation was made against Carroll's Residential Care regarding facility staff did not treat a resident with dignity by threatening to evict the resident for an unkempt room. LPA Hall interviewed the residents and staff members who may have witnessed or had relevant information regarding the incident. LPA reviewed relevant documentation, including resident care plans, and other relevant records. LPA observed the facility's operations, staff interactions with residents, and the overall environment. Continued on 9099C Unsubstantiated Allegation: Staff did not treat a resident with dignity. After conducting interviews with residents and staff members, no evidence was found to support the claim. The resident's statements were consistent with the witness. However, the complainant also witnessed the resident's room in previous times as: "the dresser would be messy with plates, empty cups and cans on the dresser." Which would violate the house rules of the facility: "The room must be clutter-free at all times. If you fail to keep your room clutter-free and refuse to work with management you will be given notice to move out." Based on the investigation findings, the allegation made against Carroll's Residential Care regarding Staff did not treat a resident with dignity is unsubstantiated. There is no evidence to support the claims that the resident was threatened with being evicted only that the resident was reminded of house rules of keeping the room clean is a part of the admission agreement and eviction was possible with repeated violations. A finding that is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with the Assistant Manager. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Assistant Manager and her signature on this report confirms receipt of the Licensee Rights.the state’s words, verbatim · CDSS document, Dec 12, 2023 · control 08-AS-20231019143629

Allegation investigated: Staff did not meet a resident's incontinence needs

Licensing Program Analyst (LPA) Renita Hall, conducted an unannounced visit to open a complaint and deliver findings regarding the above-mentioned allegation LPA was allowed entry by Sarita Mendoza, Assistant Manager. LPA identified herself and disclosed the purpose of the visit and elements of the findings to the Assistant Manager. On December 8, 2023, an allegation was made against Carroll's Residential Care regarding the staff not meeting a resident's incontinence needs. LPA Hall interviewed the resident and staff members who may have witnessed or had relevant information regarding the incident. LPA reviewed relevant documentation, including resident care plans, and other relevant records. LPA observed the facility's operations, staff interactions with residents, and the overall environment. Continued on 9099C Unsubstantiated Allegation: Staff did not meet a resident's incontinence needs. No evidence was found to support the claim after conducting interviews with the resident and staff members. The resident's physician report indicated that the resident is capable of meeting their incontinence care with no additional assistance needed. Resident 1 (R1) stated that they can manage their Activities of Daily Living (ADLs) with no assistance but if needed they will ask staff to assist. Based on the investigation findings, the allegation made against the staff of Carroll's Residential Care regarding staff not meeting a resident's incontinence needs is unsubstantiated. A finding that is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with the Assistant Manager. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Assistant Manager and her signature on this report confirms receipt of the Licensee Rights.the state’s words, verbatim · CDSS document, Dec 12, 2023 · control 08-AS-20231208091532

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Renita Hall conducted an unannounced case management visit to follow-up on an incident reported to Community Care Licensing. LPA met with Sarita Mendoza, Assistant Manager, and discussed the purpose of the visit. On 11/06/23, at approximately 5:00 PM, staff was alerted to an emergency situation involving Resident 1 (R1) Staff heard R1 exhibiting signs of choking. Immediate life-support protocols were initiated, and the Heimlich maneuver was attempted to relieve the obstruction. Staff 2 promptly called emergency medical services (EMS) and Staff 1 and Staff 3 continued their efforts to clear the airway obstruction until the arrival of the EMS team. During today’s visit, LPA performed a brief facility tour and welfare check on residents, finding that they were safe and alert. LPA also reviewed pertinent care records and interviewed relevant staff. Based on evidence, circumstances, and context obtained through reviewed records and interviews, no deficiency was cited for the above incident. Also, no deficiency was observed during today’s site visit. An exit interview was conducted with Sarita Mendoza, Assistant Manager. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Assistant Manager and her signature on this report confirms receipt of the Licensee Rightsthe state’s words, verbatim · CDSS document, Nov 13, 2023