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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320283
Report Date: 04/10/2024
Date Signed: 06/24/2024 04:32:12 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/05/2024 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240405160953
FACILITY NAME:VERNON COTTAGEFACILITY NUMBER:
198320283
ADMINISTRATOR:UMANA, JOSEFACILITY TYPE:
740
ADDRESS:2312 ROSWELL AVETELEPHONE:
(562) 342-6145
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY:6CENSUS: 6DATE:
04/10/2024
UNANNOUNCEDTIME BEGAN:
08:38 AM
MET WITH:Elsa Roman, AdministratorTIME COMPLETED:
04:54 PM
ALLEGATION(S):
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Staff member engages in inappropriate behavior with family member in the presence of resident in care.
INVESTIGATION FINDINGS:
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On 06/24/2024, Licensing program Analyst (LPA) Mario Leon conducted a follow-up, unannounced, visit to the above-mentioned facility to deliver this amended document originally delivered on 04/25/2024. LPA was met by Elsa Roman, Assistant Administrator.
The investigation consisted of the following:
On 04/10/2024, Licensing program Analyst (LPA) Mario Leon conducted an initial complaint visit at the above-mentioned facility. LPA was met by Alexander Ramos, Caregiver (S2). LPA was later met by Elsa Roman, Administrator (S1), and the purpose of the visit was explained. On 04/10/2024 LPA requested facility documents for all staff who were present during resident one's (R1) presence and R1's hospice care plan. LPA interviewed four (4) staff who were present at the facility and three (3) out of six (6) residents. 3 residents were not available for interview. LPA interviewed two (2) witnesses. LPA conducted a plant inspection and records were reviewed.

Report continues, see LIC9099C
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
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 11-AS-20240405160953
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: VERNON COTTAGE
FACILITY NUMBER: 198320283
VISIT DATE: 04/10/2024
NARRATIVE
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The investigation revealed the following:
Regarding the allegation: "Staff member engages in inappropriate behavior with family member in the presence of resident in care.". It has been alleged that family member(s) was in R1's room having a private conversation with R1 and S2 interrupted the family member and R1's conversation.

Interviews revealed that 4 out of 4 staff, 3 out of 3 residents and 2 out of 2 witnesses have denied the allegation. Record reviews revealed that all 4 staff have appropriate training records, according to CA Code of Regulations: Title 22, Division 6, Chapter 8 - Article 07. "87411 Personnel Requirements - General".

Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

An exit interview was conducted with Elsa Roman, Assistant Administrator, and a copy of this report has been provided.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2