198603464-4-22-2025-28-AS-WSHO-DKWS4G-20250826133240

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603464
Report Date: 04/22/2025
Date Signed: 04/22/2025 02:05:39 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/14/2025 and conducted by Evaluator Mary G Flores

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250414161453

FACILITY NAME:	AMELIA ROSE SENIOR CARE COTTAGE		FACILITY NUMBER:	198603464
ADMINISTRATOR:	DALLAS, CHERYL Y.		FACILITY TYPE:	740
ADDRESS:	3210 WOLFE ST		TELEPHONE:	(310) 438-3978
CITY:	LAKEWOOD	STATE: CA	ZIP CODE:	90712
CAPACITY:	6	CENSUS: 6	DATE:	04/22/2025
		UNANNOUNCED	TIME BEGAN:	09:22 AM
MET WITH:	Sherie Betters- House Manager		TIME COMPLETED:	02:19 PM

ALLEGATION(S):

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Licensee does not ensure that the facility has a sufficient quantity of food for residents in care.
Staff member does not ensure that resident participates in activities while in care.
Staff member do not ensure that residents are adequately fed while in care.
Staff members do not treat residents with dignity and respect
Licensee did not address report roach infestation at facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Sherie Betters and explained the reason for the visit.

The investigation consisted of the following: LPA requested copies of resident/staff roster. LPA conducted a tour of the home with Sherrie . LPA interviewed 6 residents and 2 staff. LPA requested copies the following documents: resident/staff roster, menu, activity calendar, training for 2 staff, designee notification, physician’s report, appraisal, identification and emergency information sheet for resident #1-2(R1-R2), and hospital discharge documents for Resident #3(R3), pest control records.

The investigation revealed the following: Regarding allegation: Licensee does not ensure that the facility has a sufficient quantity of food for residents in care and Staff member do not ensure that residents are adequately fed while in care.
(CONTINUED ON LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025

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 28-AS-20250414161453

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: AMELIA ROSE SENIOR CARE COTTAGE	FACILITY NUMBER: 198603464
	VISIT DATE: 04/22/2025

NARRATIVE

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It is alleged the facility does not have a lot of food on hand and residents are hungry because they have not been fed. Interviews conducted with residents revealed, 4 out of 6 residents stated to be served their meals with a variety of foods and are content with the food and 2 out of 6 residents were unable to provide answers due to cognitive skills. Interviews with staff and administrator revealed groceries are purchase once a week and there is a menu which is followed by the staff. During facility’s tour LPA observed adequate amount of food supplies. LPA observed items as follow: in the freezer there was fish, meat, chicken, frozen vegetables. In the refrigerator milk, fruits, turkey, yogurt, vegetables, tortillas, fruits were observed. In the pantry can foods, and dry goods (oatmeal, cereals) were observed. During the visit all residents were at the dining table, one of them was finishing breakfast and the staff prepared lunch which matches the lunch posted on the menu. LPA reviewed the menu posted in the kitchen’s wall.

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

Regarding allegation: Staff member does not ensure that resident participates in activities while in care. It is alleged resident lays in bed all day. Interviews with residents revealed 3 out of 6 residents stated to have activities throughout the day, like exercises. One of the residents stated all residents have meals together. 3 out of 6 residents were unable to answer due to cognitive skills. Interviews with administrator and staff revealed there is an activity calendar and the residents paint, play bingo, do arts and crafts, exercise, and do celebrations. During LPA’s visits all residents were observed in the dining room upon arrival, finishing breakfast. An activity calendar was posted in the living room and dining room. Pictures of celebrations and arts and crafts were posted around the dining room. LPA observed materials for activities stored in the a cabinet in the dining room.

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

Regarding allegation: Staff members do not treat residents with dignity and respect. It is alleged residents are treated rough while providing care and are being yelled at. Interviews with 4 out of 6 residents stated staff treat them well, are gentle, and respectful at all times. 2 out of 6 residents were unable to answer due to cognitive skills. (CONTINUED ON LIC 9099C)

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20250414161453

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: AMELIA ROSE SENIOR CARE COTTAGE	FACILITY NUMBER: 198603464
	VISIT DATE: 04/22/2025

NARRATIVE

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Interviews with staff revealed residents are being treated with respect and have not observed or been reports of staff mistreating the residents while in care. Per administrator staff receive initial training which includes resident rights.

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

Regarding allegation: Licensee did not address reported roach infestation at facility. It is alleged there is a roach infestation. Interviews with residents revealed 4 out of 6 residents stated the facility is clean and 2 out of 6 residents were unable to answer due to cognitive skills. Interviews with staff revealed there has not been a cockroach infestation at the facility. Per administrator pest control is provided at the facility once a month. During the facility’s tour LPA observed living room, kitchen, dining room, bathrooms, and each residents’ room free of cockroaches. There was no evidence of an infestation under the kitchen’s sink or bathrooms’ sinks. LPA reviewed pest control invoice dated 4/21/25.

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

Exit interview was conducted with Cheryl Dallas administrator and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025

LIC9099 (FAS) - (06/04)

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