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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320283
Report Date: 04/26/2024
Date Signed: 06/24/2024 04:42:32 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
04/17/2024 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240417145929
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: 5DATE:
04/26/2024
UNANNOUNCEDTIME BEGAN:
08:01 AM
MET WITH:Jose Umana, AdministratorTIME COMPLETED:
03:17 PM
ALLEGATION(S):
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Licensee did not allow a resident to have a visitation
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 04/26/2024. The purpose of this amended document is to remove identifying information from the narrative. LPA was met by Edgar Yraheta, Administrator Assistant, and the purpose of the visit was explained.
The investigation consisted of the following:
On 04/26/2024 LPA conducted an initial complaint visit at the above-mentioned facility. LPA was met by Shawellyn Martin, Caregiver (S4). LPA was later met by Jose Umana, Administrator (S1) and Edgar Yraheta, Administrator Assistant (S2) and the purpose of the visit was explained. On 04/25/2024 LPA requested facility documents for all visits conducted by Long Beach Police Department (LBPD) on 04/13/2024. On 04/26/2024 LPA interviewed four (4) staff (S1-S4) and three (3) out of five (5) residents (R1-R3), two (2) residents (R4-R5) were resting and preferred not to be interviewed, and two (2) witnesses (W1-W2). 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: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024
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-20240417145929
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: 04/26/2024
NARRATIVE
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The investigation revealed the following:
Regarding the allegation: "Licensee did not allow a resident to have a visitation". It has been alleged that on 4/13/2024 visitor(s) were asked to leave the facility during visiting hours. Record reviews revealed the following: The Sign in/out sheet, on 04/13/2024, logged that a visitor was there to visit a resident. The facility house rules indicates that residents are allowed to have visitors between the hours of 09:00AM - 7:00PM, but that "visitors must be respectful of other residents and staff. Disruptive guests will be asked to leave.". Record reviews of the Serious Incident Report (SIR), submitted on 04/17/2024, indicates that on 04/13/2024 around 11:30AM a visitor was escorted out of the facility by LBPD officers after verbally threatening staff and family member(s). Interviews revealed the following: 4 out of 4 staff and 3 out of 3 residents have disagreed with the allegation. Interviews also indicate that on 04/13/2024 Administrator S1 and LBPD requested a visitor to depart from the facility due to that visitor’s disruptive behavior to staff, which disrupted three (3) residents in care.

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.

There have been no deficiencies cited today.

An exit interview was held with Edgar Yraheta (S2) and a copy of this report has been provided.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2