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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609865
Report Date: 03/18/2024
Date Signed: 03/18/2024 02:51:41 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/26/2023 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20230626091233
FACILITY NAME:COTTAGES OF LAKE BALBOA 1, THEFACILITY NUMBER:
197609865
ADMINISTRATOR:LEVI, JUSTINFACILITY TYPE:
740
ADDRESS:6724 GAVIOTA AVETELEPHONE:
(747) 264-1004
CITY:LAKE BALBOASTATE: CAZIP CODE:
91406
CAPACITY:6CENSUS: 4DATE:
03/18/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Angie De Leon - Assistant Administrator TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff locked resident in a facility bedroom

Resident's grooming needs were not met by facility staff

Resident in care was locked out of the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver final findings of allegations listed above. During today’s visit, LPA met with Angie De Leon and explained the reason for the visit.

On 07/03/2023, from 11:30 a.m. – 3:30 p.m., LPA initiated an unannounced complaint investigation for the allegations listed above. During the visit, LPA toured the physical plant, interviewed staff, resident and reviewed and obtained pertinent documents relevant to the investigation. On 10/30/2023, from 10:30 a.m. – 3:00 p.m., LPA conducted a subsequent complaint visit. During the visit, LPA toured physical plant, interviewed staff, families / responsible parties of residents in care and reviewed and obtained copies of additional documentation relevant to the investigation.

It was reported that Staff locked resident in a facility bedroom, as it was alleged that Resident #1 (R1) was observed locked in their bedroom.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
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 3
Control Number 29-AS-20230626091233
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COTTAGES OF LAKE BALBOA 1, THE
FACILITY NUMBER: 197609865
VISIT DATE: 03/18/2024
NARRATIVE
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Continued from 9099
Interviews conducted with five (5) residents, five (5) staff and four (4) families of residents in care revealed , that no one has observed any resident locked in their bedroom. During physical plant on the initial complaint visit, LPA observed that each bedroom door swung open towards the inside of the bedroom and each door did not have a lock. LPA’s interview with four (4) family member / responsible parties of residents in care revealed that each did not express any potential or immediate concerns for any resident to be locked in a bedroom. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff locked resident in a facility bedroom” is deemed Unsubstantiated at this time.

It was reported that Resident’s grooming needs were not met by facility staff, as it was alleged that Resident #2 (R2)’s fingernails were observed to be long and dirty on multiple occasions. In addition, R2’s hair appeared to not have been brushed multiple times. LPA’s records review revealed that staff logged the following items daily; Residents food intake, toileting / bowel movements, and shower assistances. LPA did not observe anything in the records that indicated that any residents grooming needs were not met. Interviews conducted with five (5) staff revealed that each staff member have always observed R2 to appear to be bathed and groomed. Each staff also stated they have never observed R2’s finger nails to be long and dirty. In addition, the staff interviewed further revealed that a podiatrist visits the facility approx. every ninety day or upon request to service each resident. LPA's interview with Podiatrist revealed they have never observed any resident with long and dirty fingernails. LPA’s interview with four (4) family member / responsible parties of residents in care along revealed that each did not express any potential or immediate concerns for residents’ grooming needs not being met by facility staff. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Resident’s grooming needs were not met by facility staff” is deemed Unsubstantiated at this time.

It was reported that resident in care was locked out of the facility as it was alleged that on one occasion R1 was locked out at the front door of the facility. Time and day of alleged incident were not provided to LPA. Interviews conducted with five (5) staff and five (5)residents revealed that each person interviewed have never observed any resident locked out of the facility.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 29-AS-20230626091233
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COTTAGES OF LAKE BALBOA 1, THE
FACILITY NUMBER: 197609865
VISIT DATE: 03/18/2024
NARRATIVE
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Continued from 9099-C

LPA’s interview with four (4) family member / responsible parties of residents in care revealed that each did not express any potential or immediate concerns for any residents being locked out of facility. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “resident in care was locked out of the facility” is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3