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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607071
Report Date: 03/28/2023
Date Signed: 03/28/2023 01:09:25 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/21/2023 and conducted by Evaluator Angelica Rea
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230321170306
FACILITY NAME:CHLOIE'S COTTAGEFACILITY NUMBER:
197607071
ADMINISTRATOR:LINDA RENARDFACILITY TYPE:
740
ADDRESS:747 N. BELLEVIEW AVENUETELEPHONE:
(909) 599-3193
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:6CENSUS: 4DATE:
03/28/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Linda Renard TIME COMPLETED:
01:25 PM
ALLEGATION(S):
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Staff does not rotate and reposition resident causing resident to sustain pressure injury(ies).
Staff forced lollipop into resident’s mouth.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angelica Rea conducted a visit in response to the above allegations. On today's visit, LPA met with staff, Arlene Meixner, who allowed entry into the facility and assisted with today's visit. Administrator Linda Renard arrived at the facility a short time later and also assisted with the visit.

Regarding the allegation that staff does not rotate and reposition resident #1 causing resident #1 to sustain pressure injury(ies). The investigation consisted of interviews with Hospice nurse, Administrator, Staff #1 - Staff #3, and Resident #4. Resident #1 - Resident #3 were not interviewed due to cognitive impairment. Hospice nurse stated that Resident #1 does not currently have any pressure injuries. Administrator and Staff interviewed denied the allegation. They denied that resident(s) have pressure injuries and stated that resident(s) are repositioned every 2 hours. Resident #4 was unable to corroborate the allegation. Resident #4 stated that they did not know if residents have pressure injuries.

Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 28-AS-20230321170306
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CHLOIE'S COTTAGE
FACILITY NUMBER: 197607071
VISIT DATE: 03/28/2023
NARRATIVE
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Regarding the allegation that staff forced a lollipop into resident #1's mouth. The investigation consisted of interviews with Administrator, Staff #1 - Staff #3, and Resident #4. Resident #1 - Resident #3 were not interviewed due to cognitive impairment. Administrator and Staff interviewed stated that resident #1's daughter brought lollipops for resident #1. Staff stated that resident #1 sometimes has "continuous chattering" and they offer resident #1 a lollipop. Staff stated this is very rare, and doesn't happen often. Staff stated that resident #1 enjoys the lollipop. Resident #4 was unable to corroborate the allegation, resident #4 stated that they don't force the lollipop into resident #1's mouth.

Based on LPA's observations and interviews, investigation revealed: Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted, and a copy of report was provided to Administrator, Linda Renard.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2