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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609873
Report Date: 11/02/2021
Date Signed: 11/02/2021 05:08:39 PM

Substantiated


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
07/28/2020 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 29-AS-20200728111220
FACILITY NAME:COTTAGES OF LAKE BALBOA 3, THEFACILITY NUMBER:
197609873
ADMINISTRATOR:LEVI, JUSTINFACILITY TYPE:
740
ADDRESS:6726 GAVIOTA AVETELEPHONE:
(747) 264-1116
CITY:LAKE BALBOASTATE: CAZIP CODE:
91406
CAPACITY:6CENSUS: 4DATE:
11/02/2021
UNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Justin LeviTIME COMPLETED:
05:10 PM
ALLEGATION(S):
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Resident was not accorded dignity in their relationships with staff.
Facility staff do not respond to resident's request for assistance in a timely manner
Facility did not provide basic personal care services to resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation for the allegations listed above. LPA arrived at the facility at 9:52 AM and met with Justin Levi, the Licensee. Entrance interview conducted.

During today's visit, LPA interviewed Licensee at 10:27 AM, conducted resident interviews from 11:45 AM to 12:40 PM, staff interviews at 10:54 AM and 12:43 PM, toured the facility with Licensee at 11:33 AM, and reviewed pertinent resident file information. During a virtual initial complaint inspection on 08/07/2020, LPA Dulek conducted a telephone interview with the Licensee and a video call at 3:15PM which consisted of a of a physical plant tour to ensure health and safety of the residents and testing the call button system, which was functional at the time of the visit. During a subsequent complaint visit on 06/10/2021, LPA interviewed Licensee at 12:05PM, conducted staff interviews from 12:27 to 1:10 PM, interviewed Resident #1 at 1:13 PM, and received copies of documents pertinent to the investigation. The following was then determined:
REPORT CONTINUED ON LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
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 7
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
07/28/2020 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 29-AS-20200728111220

FACILITY NAME:COTTAGES OF LAKE BALBOA 3, THEFACILITY NUMBER:
197609873
ADMINISTRATOR:LEVI, JUSTINFACILITY TYPE:
740
ADDRESS:6726 GAVIOTA AVETELEPHONE:
(747) 264-1116
CITY:LAKE BALBOASTATE: CAZIP CODE:
91406
CAPACITY:6CENSUS: 4DATE:
11/02/2021
UNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Justin LeviTIME COMPLETED:
05:10 PM
ALLEGATION(S):
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Admission agreement did not include information about rate changes.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint investigation for the allegations listed above. LPA arrived at the facility at 9:52 AM and met with Justin Levi, a facility Administrator. Entrance interview conducted.

During today's visit, LPA interviewed Administrator at 10:27 AM, conducted resident interviews from 11:45 AM to 12:40 PM, staff interviews at 10:54 AM and 12:43 PM, toured the facility with Administrator at 11:33 AM, and reviewed pertinent resident file information. During a virtual initial complaint inspection on 08/07/2020, LPA Dulek conducted a telephone interview with the administrator and a video call at 3:15PM which consisted of a of a physical plant tour to ensure health and safety of the residents and testing the call button system, which was functional at the time of the visit. During a subsequent complaint visit on 06/10/2021, LPA interviewed Administrator at 12:05PM, conducted staff interviews from 12:27 to 1:10 PM, interviewed Resident #1 at 1:13 PM, and received copies of documents pertinent to the investigation. The following was then determined:
REPORT CONTINUED ON LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20200728111220
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 3, THE
FACILITY NUMBER: 197609873
VISIT DATE: 11/02/2021
NARRATIVE
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LPA Dulek reviewed a copy of R1's signed Admissions Agreement dated 05/12/2019, including section #9 on Rate Change. This section states that "the cost of providing services by facility to resident is subject to modification upon sixty (60) days notice from facility to resident and/or his/her responsible party, if any..." LPA was also provided a copy of a letter dated 07/27/2020 indicating there will be a rate increase effective October 2020, which provided the resident the required 60 days notice. Interviews revealed the letter was issued to the resident with greater than 60 days notice. Based on interviews and record review, at this time there is insufficient evidence to support the allegation, therefore, the allegation that "admission agreement did not include information on rate changes" is deemed UNSUBSTANTIATED at this time.

No deficiencies cited. Exit interview conducted. A copy of the report was provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 29-AS-20200728111220
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 3, THE
FACILITY NUMBER: 197609873
VISIT DATE: 11/02/2021
NARRATIVE
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Regarding the allegation "Resident was not accorded dignity in their relationships with staff:"

Interviews revealed that Resident #1 (R1) has care needs that differ from those of the other residents. R1 is non-ambulatory and is particular about how R1's care needs are met. R1 will let facility staff know when R1 is unhappy with the care being provided. According to R1's family member, they understand that R1 can be difficult and is not always kind to the caregivers. Facility staff interviews revealed that R1 yells at them regularly and only wants certain caregivers assisting with R1. R1's needs and service appraisal indicates R1 is "incredibly nasty to caregivers - potential for caregivers to quit." Interviews revealed that facility staff try to be patient with R1 when R1 yells at them, however sometimes caregivers lose their patience with R1. Interviews revealed that staff have raised their voice with R1. Therefore, based on interviews and record review, the allegation that "Resident was not accorded dignity in their relationships with staff" is deemed SUBSTANTIATED at this time.

Regarding the allegation "Facility staff do not respond to resident's request for assistance in a timely manner:"

LPA reviewed text message documentation provided by R1 indicating there are times when R1 waits for assistance for hours prior to staff entering R1's room to assist them. Interviews revealed that R1 calls for assistance frequently throughout the day and night time. During the night, there is one care staff scheduled for the home and R1 does require 2-person assistance, so when R1 has care needs at night, care staff are unable to respond timely. R1's call pendant wasn't working for some time and R1 was required to call out for assistance. Often times R1 has to call on their cell phone in order to get a caregiver to come assist them. Interviews revealed that residents feel it takes too long for care staff to respond. Therefore, based on interviews and record review, the allegation that "Facility staff do not respond to resident's request for assistance in a timely manner" is deemed SUBSTANTIATED at this time.

Regarding the allegation "Facility did not provide basic personal care services to resident:"

LPA reviewed R1's needs and service appraisal and physician's report, both of which indicate R1 can feed thyself, but requires assistance with all other ADLs. During the subsequent complaint inspection on 06/10/2021, LPA observed R1's hair to be oily and very tangled/matted in the back. R1 indicated that their hair
Report Continued on LIC 9099-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 29-AS-20200728111220
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 3, THE
FACILITY NUMBER: 197609873
VISIT DATE: 11/02/2021
NARRATIVE
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had not been washed in over 6 months. Staff interviews revealed that R1 frequently refuses when facility staff offer to provide care. LPA reviewed documentation for May 2021 indicating the resident refused care 23 days and was out of the facility for 2 days. The remaining 6 days, there is no documentation of refusal. No documentation provided indicated that the physician was notified when R1 refused care or that additional measures were taken to ensure R1's personal care needs were met in spite of the resident's refusal. Therefore, based on observation and interview, the allegation that "facility did not provide basic care services to the resident" is deemed SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted, todays reports, and appeal rights were reviewed and emailed to the Licensee/Administrator.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 29-AS-20200728111220
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 3, THE
FACILITY NUMBER: 197609873
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/03/2021
Section Cited
CCR
87464(f)(4)
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87464 Basic Services (f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing...in Section 87608, Postural Supports.
This requirement is not met as evidenced by:
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Administrator agreed to immediately ensure staff are regularly offering to wash R1's hair and ensure all residents' personal care needs are met. Additional training to be provided to staff on working with R1. Administrator will provide CCL with a detailed plan on how the facility will handle care refusal including who will be notified and when care needs are
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Based on observation and interviews, R1's hair had not been washed or brushed regularly, which poses an immediate health and personal rights risk to residents in care.
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refused by 11/10/2021.
Type A
11/16/2021
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement is not met as evidenced by:
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Licensee agreed to train all staff on section 87468.1. Training to be held and a copy of the roster including information on trainer, attendees, topics covered, date and duration of training to be sent to CCL by POC due date.
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Based on observation and interviews, facility staff have raised their voice with R1 and do not respond timely to R1's requests for assistance, which poses an immediate personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 7