198602568-8-7-2025-11-AS-JHAD-DKT2DQ-20250822171843

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602568
Report Date: 08/07/2025
Date Signed: 08/07/2025 12:59:23 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
04/01/2025 and conducted by Evaluator Zina Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20250401104354

FACILITY NAME:	MOM & DAD'S HOUSE-COTTAGE		FACILITY NUMBER:	198602568
ADMINISTRATOR:	MEADER, IVONNE A		FACILITY TYPE:	740
ADDRESS:	5413 E CONANT ST		TELEPHONE:	(949) 381-1792
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90808
CAPACITY:	6	CENSUS: 6	DATE:	08/07/2025
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Ivonne Meader, Administrator		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Resident sustained an unexplained fracture while in care.

INVESTIGATION FINDINGS:

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On 08/07/2025 at 12:15 PM, Licensing Program Analyst (LPA) Zina Brown conducted a subsequent visit at this facility to deliver the complaint findings. During today's visit, LPA met with Ivonne Meader, Administrator and explained the purpose of the visit.

The investigation consisted of the following:
An initial complaint visit was completed by the Department on 04/10/2025. LPA requested and reviewed the following documents: Register of Facility Clients/Residents, LIC 601: Identification and Emergency Information (dated 06/16/2024) for Resident 6 (R6), LIC 602A: Physician's Report for Residential Care Facilities for the Elderly (RCFE) – dated 11/22/2024 for R6, Resident Appraisal – dated 07/08/2025 for R6, Appraisal/Needs and Services Plan – dated 07/01/2024, LIC 624 Unusual Incident/Injury Reports – dated 03/28/2025, 10/21/2024, 09/04/2024, and 07/15/2024 and Medical Records (from Memorial Long Beach Medical Hospital - dated 04/17/2025) for R6 received on 04/17/2025.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025

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 11-AS-20250401104354

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: MOM & DAD'S HOUSE-COTTAGE	FACILITY NUMBER: 198602568
	VISIT DATE: 08/07/2025

NARRATIVE

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The investigation revealed the following:

Allegation 1: Resident sustained an unexplained fracture while in care.
It was alleged that a Resident sustained an unexplained fracture due to lack of supervision or negligence while residing at the facility. On 07/08/2025 at 10:40 AM, LPA interviewed A1 (Administrator). A1 denied the allegation and stated that R6 injury was reported promptly to the physician, the responsible party was notified, and the incident occurred when staff was not present in the immediate area, but there were no signs of abuse or neglect. A1 indicated that staff follow protocol, and the resident had a history of unsteady gait despite using a walker. On the date of the incident, R6 was sitting in his wheelchair at the dining table. Between 9:30 AM and 10:15 AM, LPA interviewed 2 staff regarding the allegation: 2 of 2 staff denied the allegation. Between 8:35 AM - 9:13 AM, LPA interviewed 3 residents: 2 out of 3 residents denied the allegation. 1 out of 3 residents was unaware of the allegation.

LPA conducted a records review on 06/25/2025, between the hours of 11:06 AM - 11:45 AM & 08/07/2025, between the hours of 9:20am - 9:30am and observed the following: The LIC 624: Unusual Incident/Injury Report dated 03/28/2025, R6 was sitting around the table when S1 heard a sound coming from the dining room and S1 witnessed R6 on the floor. Staff called 911 and notified the assistant administrator. The assistant administrator called R6's POA who was able to come to the facility at the same time as paramedics. POA insisted that R6 was okay and did not need transportation to the hospital. Paramedics agreed and he was not transported to the hospital. The resident was admitted to the facility on 06/18/2024. According to the Physician’s Report, the resident has been diagnosed with dementia, is non-ambulatory, and requires assistance with grooming, bathing, and feeding.

Report continues on LIC 9099-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20250401104354

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: MOM & DAD'S HOUSE-COTTAGE	FACILITY NUMBER: 198602568
	VISIT DATE: 08/07/2025

NARRATIVE

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The report further notes that the resident experiences generalized muscle weakness, uses both a walker and wheelchair, and is able to follow instructions and communicate his needs. A Resident Appraisal dated 07/08/2024 documents additional conditions, including left hip arthritis, episodes of sundowning, and frequent hallucinations. According to the resident’s Needs and Services Plan, the resident requires assistance with all Activities of Daily Living (ADLs), has mobility limitations due to physical and cognitive impairments, and is at increased risk for falls. The plan includes supervision for safety, cueing and support for memory-related deficits, and assistance with medication management, hygiene, and mobility transfers. The LIC 624 – Unusual Incident/Injury Report was submitted to document a significant incident resulting in the resident’s hospitalization. The form outlines the date, time, nature of the injury, immediate response by facility staff, and notifications made to the resident’s responsible party and licensing agency. Per the Memorial Care Emergency Department to Hospital Admission form, the resident was admitted to the hospital on 03/28/2025 at 7:28 PM under Trauma status. The admitting diagnosis was a left displaced femoral neck fracture, requiring further treatment.

Based on interviews and record review conducted there is no not enough evidence to support that the facility staff did not provide enough supervision to the resident therefore the allegation is UNSUBSTANTIATED.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with Ivonne Meader, Administrator & copy of the report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025

LIC9099 (FAS) - (06/04)

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