197610364-7-15-2025-31-AS-TAGD-DKKQ4Q-20250815115043

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610364
Report Date: 07/15/2025
Date Signed: 07/15/2025 11:38:34 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/30/2025 and conducted by Evaluator Tuesday Cabiness

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20250630114223

FACILITY NAME:	ANITA'S COTTAGE		FACILITY NUMBER:	197610364
ADMINISTRATOR:	GURULE, MARIO		FACILITY TYPE:	740
ADDRESS:	27736 SYCAMORE CREEK ROAD		TELEPHONE:	(818) 667-8166
CITY:	VALENCIA	STATE: CA	ZIP CODE:	91354
CAPACITY:	5	CENSUS: 3	DATE:	07/15/2025
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Mario Gurule		TIME COMPLETED:	11:50 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

1.Staff are not qualified to administer medication to residents
2.Staff did not administer medications as prescribed

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Tuesday Cabiness arrived to the facility at 10:27am to conduct a subsequent visit and deliver the final findings and report. LPA met with Administrator Mario Gurule and informed him the reason of the visit. The following was determined:

Allegation #1: .Staff are not qualified to administer medication to residents. To investigate the allegation, on 07/09/2025, from 10:00 a.m. to 11:00 a.m., LPA interviewed the complainant and reviewed the complaint. On 07/10/2025, from 9:15 a.m. to 1:45 p.m., LPA conducted an unannounced visit to the facility, interviewed staff and residents, and reviewed resident and facility documentation. Information obtained during the investigation revealed concerns that staff were hesitant to administer narcotic medication to resident #1 (R1), and it was reported that staff refused to provide pain medication that was scheduled. However, staff interviews indicated that although R1 was in extreme pain due to a medical diagnosis, staff administered the prescribed medication in accordance with physician orders to alleviate the resident’s discomfort. Staff acknowledged the emotional difficulty of witnessing a resident in severe pain but affirmed their understanding of their responsibilities as

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025

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 31-AS-20250630114223

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANITA'S COTTAGE	FACILITY NUMBER: 197610364
	VISIT DATE: 07/15/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

caregivers to provide appropriate care. Staff interviewed have been employed at the facility for over four years and reported no prior issues related to medication administration. Residents interviewed also stated that staff consistently administer medication without any problems. LPA reviewed staff medication training records, which were observed to be current and up to date. Based on interviews conducted and documentation reviewed, there is insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

Allegation # 2: Staff did not administer medications as prescribed. To investigate the allegation, on 07/09/2025, from 10:00 a.m. to 11:00 a.m., (LPA) interviewed the complainant and reviewed the complaint. On 07/10/2025, from 9:15 a.m. to 1:45 p.m., LPA conducted an unannounced visit to the facility, interviewed staff and residents, and reviewed resident and facility documentation. Information obtained during the investigation revealed that resident #1 (R1) was admitted to the facility on 06/22/2025 under hospice care due to a terminal illness. According to the resident’s medication records, staff administered R1’s medications in accordance with the physician’s orders. After five days at the facility, R1’s condition began to decline, prompting the physician to update the medication orders. Documentation reviewed from both facility/staff records and hospice records confirmed that staff continued to administer medications as prescribed by the attending physician. Additionally, residents interviewed by LPA reported receiving their medications without any issues. Based on interviews and a review of documentation, there is insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted, copy of report provided to Administrator.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 2