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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609873
Report Date: 03/04/2022
Date Signed: 03/04/2022 01:37:05 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,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/25/2019 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20191125101741
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: 5DATE:
03/04/2022
ANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Justin LeviTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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9
Facility staff are not attending to resident's hygeine needs
Facility staff are failing to reposition the resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent visit to finish investigation into the allegations above. LPA met with the administrator and explained the reason for this visit.
Initial visit regarding these allegations was conducted on 11/26/2019.

Facility staff are not attending to resident's hygeine needs
It is alleged that the facility staff failed to change resident #1 (R1) bed sheets consistently, bathe R1 consistenly or change R1's catheter bag. Interviews were previously conducted with R1, facility staff, Long term care ombudsman (LTCO), and R1's home health nurse. Information from interviews revealed that R1 did not have their sheets changed or was R1 bathed consistently. Based on the information obtained through interviews this allegation is deemed Substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
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-20191125101741
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: COTTAGES OF LAKE BALBOA 3, THE
FACILITY NUMBER: 197609873
VISIT DATE: 03/04/2022
NARRATIVE
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Facility staff are failing to reposition R1
Regarding the allegation above interviews were previously conducted with R1, facility staff, and R1's home health provider. Information from interviews revealed that facility staff was not repositioning R1 as they needed to. Based on the information obtained through interviews this allegation is deemed Substantiated.

After this complaint was generated other complaints were completed and deficiencies were cited and addressed that are the same that would be cited under this complaint. See complaint control number 29-AS-20200728111220. Due to those citations already being issued and addressed after this complaint no additional citations are warranted.

Exit Interview conducted.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/25/2019 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20191125101741

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: 5DATE:
03/04/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Justin LeviTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident is not accorded privacy
Resident has several untreated wounds
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent visit to finish investigation into the allegations above. LPA met with the administrator and explained the reason for this visit.
Initial visit regarding these allegations was conducted on 11/26/2019.
Resident is not accorded privacy
It is alleged that resident # 1 (R1) is not accorded privacy. Interviews were conducted with R1 and facility staff regarding this allegation. Information revealed that R1 is afforded privacy but that R1 prefers certain staff to assist over others but sometimes R1's preferred staff is unavailable. Based on information obtained through interviews this allegation is deemed Unsubstantiated at this time.
Resident has several untreated wounds
It is alleged R1 has wounds that are untreated. Interviews were previously conducted with R1 and facility staff. LPA was able to verify that R1 had home health that were treating the wounds Based on information obtained through interviews and record review this allegation is deemed Unsubstantiated at this time. Exit Interview
conducted.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
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 3