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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609873
Report Date: 10/30/2023
Date Signed: 10/30/2023 02:50:40 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
01/21/2022 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20220121164812
FACILITY NAME:COTTAGES OF LAKE BALBOA 3, THEFACILITY NUMBER:
197609873
ADMINISTRATOR:SAENZ, NICKFACILITY TYPE:
740
ADDRESS:6726 GAVIOTA AVETELEPHONE:
(747) 264-1116
CITY:LAKE BALBOASTATE: CAZIP CODE:
91406
CAPACITY:6CENSUS: DATE:
10/30/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Justin Levi - AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff mishandled a resident's medication while in care

Staff did not address a resident's change in condition while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced complaint visit to investigate the allegations listed above. Upon arrival LPA met with Administrator Justin Levi and explained the reason for the visit.
On 01/28/2022, from 9:37 a.m. - 2 p.m., LPA initiated an unannounced complaint investigation for the allegations listed above. During the visit, LPA toured the physical plant, conducted Medication Audit, interviewed staff, residents and obtained pertinent documentation relevant to the investigation. On 06/09/2023, LPA interviewed residents and staff while on site for a separate investigation. On 10/27/2023 LPA interviewed Kaiser Home Health Nurse. Today LPA interviewed staff, residents and conducted a medication audit for residents in care.

It was reported that staff mishandled a resident’s medication while in care, as it was alleged that R1 did not receive their medication Metorolol as it was not observed in R1's 7 day pill case. Interviews conducted and records reviewed revealed that facility was using a 7 day pill case for R1's medication.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
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 2
Control Number 29-AS-20220121164812
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: 10/30/2023
NARRATIVE
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Continued from 9099
LPA's medication audits revealed R1 did have a 7 day pill case stored with their medication , but it was observed to be empty at that time. The Medication Administration Records (MAR) indicated that medications for the residents were administered as prescribed at this time. LPA also checked resident medications for expiration dates and instructions and the LPA uncovered minimal discrepancies. The LPA reviewed facility incident reports, and the LPA was unable to uncover incident reports as it related to known medication errors. Interviews revealed that staff did not recall specific occurrences where medication errors occurred. LPA's Interview with (4) four residents in care revealed they did not express any concerns as it related to receiving their medications. LPA's interview with seven (7) staff revealed they could not recall a time when a resident did not receive a medication due to error. Based on the information gathered during the investigation, the department does not have sufficient evidence to confirm this allegation occurred. Therefore, the allegation that Staff mishandled a resident’s medication while in care has been deemed Unsubstantiated at this time.

It was reported that Staff did not address a resident’s change in condition while in care, as it was alleged that facility staff did not report to R1’s home health nurse that R1 has not had a bowel movement for several days. Interviews conducted and records review revealed that R1’s home health nurse would visit R1 approximately twice a week and each time the home health nurse visited they were regularly notified about changes of condition in R1 by Staff #1 (S1) and Staff #2 (S2). Updates were also provided to the home health nurse via phone calls, emails and resident records kept at the facility. LPA records review of resident records from September 2021 to January 2022 revealed bowel movements were recorded and updated regularly during that time. Interviews conducted with seven (7) staff further revealed that if they observed a change of condition in any resident, they would notify the Administrator and notate their observations in the resident’s file. All (7) staff also indicated that when any home health nurse conducted visits, they would always update the nurse about their patient. Based on the information gathered during the investigation, the department does not have sufficient evidence to confirm this allegation occurred. Therefore, the allegation that Staff did not address a resident’s change in condition while in case has been deemed Unsubstantiated at this time.

Exit interview conducted and copy of report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2