197609873-2-17-2023-29-AS-JAPL-CPQN9M-20230308091607

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609873
Report Date: 02/17/2023
Date Signed: 02/17/2023 03:41:33 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 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
05/18/2022 and conducted by Evaluator Christine Yee

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20220518152247

FACILITY NAME:	COTTAGES OF LAKE BALBOA 3, THE		FACILITY NUMBER:	197609873
ADMINISTRATOR:	SAENZ, NICK		FACILITY TYPE:	740
ADDRESS:	6726 GAVIOTA AVE		TELEPHONE:	(747) 264-1116
CITY:	LAKE BALBOA	STATE: CA	ZIP CODE:	91406
CAPACITY:	6	CENSUS: 4	DATE:	02/17/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Justin Levi, Licensee		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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1. Staff did not ensure residents received COVID-19 vaccine.
2. Staff are not wearing masks

INVESTIGATION FINDINGS:

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Licensing Program Analyst(LPA) Christine Yee conducted an unannounced subsequent complaint visit to conduct additional investigation and to deliver the findings of the above allegations. LPA Yee met with Justin Levi, Licensee and the reason for today's visit was explained.
An initial unannounced complaint visit was conducted by LPA Brian Balisi on 5/24/22 from 1:30pm-2:30pm. LPA Balisi met with Angie Deleon, Resident Operations. During the initial visit LPA Balisi reviewed and obtained pertinent documents relevant to the complaint and conducted interviews with staff. Due to Covid-19 concerns in the facility, the visit was conducted in the facility office. The investigation was determined to need further investigation.

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

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-20220518152247

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COTTAGES OF LAKE BALBOA 3, THE	FACILITY NUMBER: 197609873
	VISIT DATE: 02/17/2023

NARRATIVE

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A subsequent unannounced complaint visit was conducted by LPA Christine Yee on 12/16/22 from 11:05am - 12:00pm to conduct further investigation of the above allegations. LPA Yee met Justin Levi, Licensee and the reason for the visit was explained. During the subsequent visit, LPA Yee obtained copies of vaccination cards for Resident #3 and #4 and conducted interview with Justin Levi, Licensee. Resident #1 was not available to be interviewed. Resident #2 through Resident #5 could not be interviewed due to dementia. The visit was terminated as needs further investigation due to insufficient information.

On 1/5/23, LPA Yee was able to reach Resident #1 via telephone at 11:02am to conduct an interview regarding the above allegations.

On today's visit LPA Yee conducted another interview with Justin Levi, Licensee at 09:25am to clarify information collected on the prior visits to the facility regarding Allegation #1- Staff did not ensure residents received COVID-19 vaccine. Per information obtained during the investigation, all facility residents had received both doses of the vaccine and the first booster shot when this complaint was received on 5/18/22. Resident #1 then requested the second booster, per Licensee in May 2022. However, there was some confusion as to the waiting period between boosters and if the other residents wanted the second booster since the pharmacy would not come to the facility for one resident. As the scheduling of the second booster shot was in the process of being addressed, the facility was impacted by Covid-19. Three residents, including Resident #1, received positive Covid-19 test results on May, 16 2022 and would not be eligible for the second booster for ninety days. This further delayed the eligibility to receive the second dose of the booster vaccine and not due to the facility's failure to ensure that
Continued on LIC9099-C

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220518152247

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COTTAGES OF LAKE BALBOA 3, THE	FACILITY NUMBER: 197609873
	VISIT DATE: 02/17/2023

NARRATIVE

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the residents received the second booster. Once Resident#1 became eligible, the second booster was administered on 8/18/22.

In regards to Allegation #2 - Staff are not wearing masks: per interviews conducted with the Licensee and Angelie Deleon, Resident Operations, the staff are required to wear a mask while working inside the facility and assisting the residents. The choice of mask to be used would be determined by whether there are any positive cases at the home. Surgical masks are worn inside the facility, if there are no positive Covid-19 cases and N-95s are required if there are positive cases. The facility provides staff with Personal Protection Equipment(PPE). The complaint states the staff wear surgical mask but should be wearing N95 daily. The staff are not required to wear N95 masks at all times as alleged in the complaint. The facility's masking protocol is in line with the guidance provided in Provider Information Notice(PIN) #21-38-ASC dated August 19, 2021. Per tour of the facility conducted from 10:49am - 10:56am today, the 2 caregivers present on today's visit, were observed wearing surgical masks.

Based on the information obtained from the investigation, it is determined that the above allegations are UNSUBSTANTIATED.

Exit interview was conducted with Angelie Deleon and a copy of this report was provided.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

LIC9099 (FAS) - (06/04)

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