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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609873
Report Date: 12/03/2021
Date Signed: 12/03/2021 03:13:02 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
03/11/2020 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 31-AS-20200311165246
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:
12/03/2021
UNANNOUNCEDTIME BEGAN:
02:23 PM
MET WITH:Justin LeviTIME COMPLETED:
03:18 PM
ALLEGATION(S):
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Staff failed to provide comfortable accommodations for resident while in care
Staff failed to ensure resident needs are properly met
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation with the purpose of delivering findings 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 an initial virtual complaint inspection on 03/20/2020, LPA Dulek conducted telephone an interview with the administrator at 12:00 PM. The LPA also requested copies of documents pertinent to the investigation be emailed to LPA. During a subsequent complaint inspection 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 conducted additional resident and staff interviews on 11/02/2021 and reviewed documents on 12/01/2021. The following was then determined:

Interviews revealed that R1 frequently refuses care. R1 is particular about the staff caring for R1 and has
REPORT CONTINUED ON LIC 9099-C
Substantiated
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)
Page: 1 of 3
Control Number 31-AS-20200311165246
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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specific care instructions R1 prefers. Record review showed R1 is a two-person assist for most personal care needs. During part of R1’s residency at the facility, R1 did have home health care, however, the home health plan indicated services were provided at a duration of 1 time per week for a 3-week period. Home health was responsible for R1’s skincare, including educating care staff how to keep skin clean and dry and Home Health was responsible for R1’s urinary device care. Facility staff were at the time and continue to be responsible for meeting R1’s personal care needs, including changing sheets/bedding, clothing, incontinence care and all other ADLs for which R1 requires assistance. Record review revealed that during the time period of February 2020, R1 had a diaper change indicated 12 out of 29 total days, sheet changed 13 out of 29 total days and wound care provided 7 out of 29 total days. Therefore, based on interviews and record review, the allegation that “staff failed to ensure resident needs are properly met” is deemed SUBSTANTIATED at this time. Additionally, based on interviews and record review, the allegation that “staff failed to provide comfortable accommodations for resident while in care” 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: 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)
Page: 2 of 3
Control Number 31-AS-20200311165246
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: 12/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/03/2021
Section Cited
CCR
87464(f)(2)
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87464 Basic Services
(f) Basic services shall at a minimum include:
(2) Safe and healthful living accommodations and services, as specified in Section 87307, Personal Accommodations and Services.

This requirement is not met as evidenced by:
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Licensee conducted a staff training on 11/17 and 11/18/2021 including basic services training. POC met at this time.
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Based on interview and record review, the licensee did not ensure R1's sheets were regularly changed, which poses a potential health risk to residents in care.
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Type B
12/03/2021
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...dressing...bathing and assistance with taking prescribed medications, as specified in Section 87608...
This requirement is not met as evidenced by:
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Licensee conducted a staff training on 11/17 and 11/18/2021 including basic services training. POC met at this time.
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Based on interview and record review, the licensee did not ensure R1's skin remained clean and dry, and incontinece needs were met, which poses a potential health 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: 12/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
LIC9099 (FAS) - (06/04)
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