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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006164
Report Date: 08/17/2023
Date Signed: 08/17/2023 10:52:14 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/10/2023 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20230710150926
FACILITY NAME:RUBY COTTAGEFACILITY NUMBER:
306006164
ADMINISTRATOR:BRAVO, VENUS SFACILITY TYPE:
740
ADDRESS:24182 MCCOY RDTELEPHONE:
(949) 583-1996
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 6DATE:
08/17/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Venus Bravo- Administrator TIME COMPLETED:
11:15 AM
ALLEGATION(S):
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The Licensee does not have liability insurance.
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry to the facility by staff Hazel Balonda , and explained the reason for the visit. Administrator Venus Bravo arrived at the facility at 9:55am.

The department received a complaint on 07/10/2023 and the initial 10 day visit was conducted on 07/18/2023. During the visit LPA Mendivil interviewed staff and obtained copies of liability insurance policies. Regarding the allegation the licensee does not have liability insurance, the investigation revealed the following:

Based on witness' report the facility had a lapse in liability insurance. Interviews with Adminstrator Venus Bravo indicate the facility did not pay for coverage timely and therefore there was a lapse in liability insurance.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023
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 3
Control Number 22-AS-20230710150926
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: RUBY COTTAGE
FACILITY NUMBER: 306006164
VISIT DATE: 08/17/2023
NARRATIVE
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Per review of liability insurance policies old policy ended on 06/08/2023 and the new policy is effective 07/20/2023 resulting in a lapse.

Therefore based on records reviewed and interviews conducted the allegation that the Licensee does not have liability insurance is determined to be SUBSTANTIATED, meaning the complaint allegation was valid and that a violation has occurred

The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8.

An exit interview was conducted and a copy of this report and appeal rights were provided to the Administrator.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20230710150926
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: RUBY COTTAGE
FACILITY NUMBER: 306006164
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/17/2023
Section Cited
HSC
1569.605
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all residential care facilities for the elderly … shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000)
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Licensee has since paid policy and updated copy was provided to LPA.
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 in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee. This requirement was not met as evidence by Licensee stated they did not pay renewal for liability insurance. This poses a potential safety risk to those 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: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3