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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005392
Report Date: 11/19/2024
Date Signed: 11/19/2024 10:25:30 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/01/2024 and conducted by Evaluator Jenifer Tirre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20241101102846
FACILITY NAME:TAYLOR COTTAGE, THEFACILITY NUMBER:
306005392
ADMINISTRATOR:CATACUTAN, MARY JEANFACILITY TYPE:
740
ADDRESS:7752 TAYLOR DRIVETELEPHONE:
(614) 746-5824
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92648
CAPACITY:6CENSUS: 4DATE:
11/19/2024
UNANNOUNCEDTIME BEGAN:
07:15 AM
MET WITH:Caregiver Quintin ClavecilasTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Resident's bedroom is used as a passageway to another room at facility
Licensee does not provide a resident privacy at the facility
INVESTIGATION FINDINGS:
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On November 19, 2024, Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced subsequent complaint visit to deliver findings. LPA Tirre met with Caregiver Clavecilas. Licensee Weenie Earwood was unavailable during visit.

The following items were revealed in complaint investigation:

Regarding allegation: Resident’s bedroom is used as a passageway to another room at facility.

During investigation, per record review, current facility sketch on file shows back room (bedroom #6) was a large room and did not indicate there are two separate rooms. Staff (S3) confirmed that bedroom used to be a large, shared room, however, the bedroom was converted into two bedrooms (#6A & 6B) with one main entry door. R1 occupies bedroom 6, staff (S4) sleeps in bedroom 6B

Interviews were conducted with three (R1-R3) of five residents and three (S1-S3) staff. interviews with Resident 1 (R1) confirmed that three male staff (S1, S2 & S4) occasionally pass through R1’s bedroom
CONTINUED ON 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
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 5
Control Number 22-AS-20241101102846
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: TAYLOR COTTAGE, THE
FACILITY NUMBER: 306005392
VISIT DATE: 11/19/2024
NARRATIVE
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 door to access the bedroom 6B for purposes of either sleeping, using restroom and or gathering personal staff belongings located in room. R2 and R3 stated they are not aware that R1’s bedroom is being used as a passageway to another bedroom. S1 and S2 confirmed that S4 sleeps in bedroom 6B. Based on the department’s observations, it was confirmed that only way through bedroom 6B is passing through Resident 1’s room 6A. The department also observed bedroom 6B has sheets and blankets on bunk bed as well as personal hygiene items located on dresser and clothing inside closet.

Regarding allegation, Licensee does not provide a resident privacy at the facility.

Interviews were conducted with three (R1-R3) of five residents and three (S1-S3) staff. Interviews with three residents (R1-R3) confirmed that staff enter resident rooms with or without notice. R1 stated S1, S2 and S4 enter R1’s bedroom 6A entrance to access bedroom 6B for the purpose of sleeping, using the bathroom or accessing their personal belongings not allowing resident privacy. Interviews with two staff (S1 & S2) revealed that they sometimes use the bathroom next to bedroom 6B and the only access is through R1’s bedroom 6A. Based on the department’s observations, it was confirmed that only way through bedroom 6B is passing through Resident 1’s room 6A.

Based on observations, interviews and record review, the preponderance of evidence has been met, therefore the allegations, “Resident’s bedroom is used as a passageway to another room at facility and Licensee does not provide a resident privacy at the facility”, are deemed SUBSTANTIATED. The following is being cited on attached LIC 9099D.

An exit interview was conducted with Caregiver Clavecilas and copies of this report along with Appeals Rights was provided.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20241101102846
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: TAYLOR COTTAGE, THE
FACILITY NUMBER: 306005392
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/02/2024
Section Cited
CCR
87307(a)(2)(C)
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87307 (a) living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:(2) resident bedrooms shall be provided which meet, at a minimum, the following requirements: (C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet. This requirement was not met as evidenced by:
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Licensee agreed to remove wall dividing bedroom #6. Licensee to transfer Resident 1 to bedroom 6Bon and use current 6A as common area until the wall is removed. Licensee agreed to obtain permit from City of Huntington Beach to remove wall inside bedroom 6 by POC due date 12/3/2024.
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R1 bedroom 6A is a passageway to staff room 6B. Based on observation the licensee did not comply with section cited above. Interview conducted with Resident 1(R1) confirmed that three male staff (S1, S2 & S4) pass through R1’s bedroom 6A door to access 6B for purposes of either sleeping, using restroom and or gathering personal staff belongings located in 6B. S1 and S2 confirmed that S4 sleeps in 6B next to R1’s bedroom 6A and they also enter through 6A. Based on the department’s observations, it was confirmed that only way through the bedroom 6B is passing through 6A. This poses a potential health, safety or personal rights risk to persons in care.
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Type B
12/03/2024
Section Cited
CCR
87468.1(a)(1)(2)
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Personal Rights(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons. (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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Licensee agrees to conduct in service training with staff regarding personal rights of residents. Licensee provide proof of training by POC due date 12/3/2024
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Staff (S1,S2 & S4) access Resident 1 (R1) bedroom 6A to get Room 6B not allowing R1 privacy. This poses a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/01/2024 and conducted by Evaluator Jenifer Tirre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20241101102846

FACILITY NAME:TAYLOR COTTAGE, THEFACILITY NUMBER:
306005392
ADMINISTRATOR:CATACUTAN, MARY JEANFACILITY TYPE:
740
ADDRESS:7752 TAYLOR DRIVETELEPHONE:
(614) 746-5824
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92648
CAPACITY:6CENSUS: 4DATE:
11/19/2024
UNANNOUNCEDTIME BEGAN:
07:15 AM
MET WITH:Caregiver Quintin ClavecilasTIME COMPLETED:
10:45 AM
ALLEGATION(S):
1
2
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Licensee is not addressing pests at the facility.
Staff do not ensure that food served to residents is free from contamination.
INVESTIGATION FINDINGS:
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On November 19, 2024, Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced subsequent complaint visit to deliver findings. LPA Tirre met with Caregiver Clavecilas
Investigations revealed:

Regarding allegation: Licensee is not addressing pests at the facility.
During investigation, interviews were conducted with three (R1-R3) of five residents and three (S1-S3) staff. Interviews with two residents (R1 & R2) and three staff (S1-S3) confirmed they observed cockroaches in the kitchen since September 2024, however, they have not observed any pests recently. One resident (R3) denied the allegation. S1-S3 stated the facility has pest control services treating the affected areas. Facility Record Review confirmed that Licensee has a monthly pest control service contract with Corky’s Pest Control that commenced on 6/30/24.

CONTINUED ON 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20241101102846
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: TAYLOR COTTAGE, THE
FACILITY NUMBER: 306005392
VISIT DATE: 11/19/2024
NARRATIVE
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Regarding allegation: Staff do not ensure that food served to residents is free from contamination.

During investigation, interviews were conducted with three (R1-R3) of five residents and three (S1-S3) staff. R1 stated they observed meat left out on stove all night and has observed staff re-use same pan with oil to cook other foods throughout day. Two residents (R2 & R3) stated they have no issues with food preparation at facility.

Based on the department’s observations, facility staff wash their hands before prepping meals, staff use separate pans for cooking and staff wear gloves while cooking.

Based on the information provided for investigation, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations, “Licensee is not addressing pests at the facility and Staff do not ensure that food served to residents is free from contamination” did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted with Caregiver Clavecilas and copy of this report along was provided.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5