197609873-12-3-2021-29-AS-KHEN-CAJUEJ-20220110143109

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609873
Report Date: 12/03/2021
Date Signed: 12/03/2021 03:15:02 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
07/28/2020 and conducted by Evaluator Kelly Dulek

COMPLAINT CONTROL NUMBER: 29-AS-20200728111220

FACILITY NAME:	COTTAGES OF LAKE BALBOA 3, THE		FACILITY NUMBER:	197609873
ADMINISTRATOR:	LEVI, JUSTIN		FACILITY TYPE:	740
ADDRESS:	6726 GAVIOTA AVE		TELEPHONE:	(747) 264-1116
CITY:	LAKE BALBOA	STATE: CA	ZIP CODE:	91406
CAPACITY:	6	CENSUS: 4	DATE:	12/03/2021
		UNANNOUNCED	TIME BEGAN:	02:23 PM
MET WITH:	Justin Levi		TIME COMPLETED:	03:18 PM

ALLEGATION(S):

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Staff did not follow physician's orders.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation for the allegation listed above with the purpose of delivering findings for the above allegation. LPA arrived at the facility at 9:52 AM and met with Justin Levi, a facility Administrator. Entrance interview conducted.

During an initial virtual 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. The LPA also requested copies pertinent documents. 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, and interviewed Resident #1 (R1) at 1:13 PM. LPA requested documents pertinent to the investigation be emailed. During a subsequent complaint visit on 11/02/2021, 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,
REPORT CONTINUED ON LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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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: 12/03/2021

NARRATIVE

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toured the facility with Administrator at 11:33 AM, and reviewed pertinent resident file information. During the course of the investigation, LPA reviewed R1’s medical record and facility file information. The following was then determined:

Interviews and record review revealed R1 schedules all their own medical appointments, arranges their own transportation, and is responsible for communicating with their own physician. Licensee interview revealed R1 has copies of their medical documentation and does not release information to the facility regularly. LPA requested copies of doctor’s orders during initial visit as well as both subsequent visits. Both R1 and Licensee were unable to provide copies of physician’s orders. LPA reviewed R1’s medical records obtained by CCL during the course of the investigation; review did not reveal orders for stretching which were referred to in the complaint. There was a statement by a nurse indicating “doctor ordered physical therapy” on 05/20/2019. No copy of the doctor's orders were contained in R1's medical record and no further information was provided. Based on interview and record review, although the allegation may be vaild, at this time there is insufficient evidence to prove the allegation occurred, therefore the allegation that “staff did not follow physician's orders” is deemed UNSUBSTANTIATED at this time.

Exit interview was conducted with Justin Levi. Report was provided via email.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021

LIC9099 (FAS) - (06/04)

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