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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006164
Report Date: 09/24/2024
Date Signed: 09/24/2024 03:31:10 PM

Unfounded


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
09/17/2024 and conducted by Evaluator Jessica Cho
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240917153724
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:
09/24/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Arnold Bravo- House Manager
Venus Bravo- Administrator		TIME COMPLETED:
03:50 PM
ALLEGATION(S):
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9
Licensee did not ensure staff completed required training hours.
Licensee did not ensure facility has a certified administrator
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose of conducting the 10-day complaint investigation into the above allegations. LPA was greeted and granted entry by Caregiver Ana Heizel Balonda and explained the reason for the visit. House Manager (HM) Arnold Bravo arrived approximately 9:20am and was advised of the visit. Administrator (Admin) Venus Bravo arrived at the facility approximately 12:10pm to complete the Personnel Report Sumary (LIC500) and assist with the investigation. During the course of the investigation, LPA interviewed six residents, four staff, and other witnesses and obtained pertinent staff records such as the Resident Roster, Personnel Report Summary, Photo Identification, Personnel Records, 2024 Caregiver's Training Records, CPR/First Aid Certificates, and Resident's Face Sheets/Physician's Reports.

The investigation revealed the following: It is alleged that the licensee did not ensure staff completed required training hours. Per review of the Personnel Report Summary, there are three caregivers currently employed to this home. Two are the primary live-in caregivers and one is a reliever.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
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 4
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
09/17/2024 and conducted by Evaluator Jessica Cho
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240917153724

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:
09/24/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Arnold & Venus BravoTIME COMPLETED:
03:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee falsified staff records.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose of conducting the 10-day complaint investigation into the above allegation. LPA was greeted and granted entry by Caregiver Ana Heizel Balonda and explained the reason for the visit. House Manager (HM) Arnold Bravo arrived approximately 9:20am and was advised of the visit. Administrator (Admin) Venus Bravo arrived at the facility approximately 12:10pm to complete the Personnel Report Sumary (LIC500) and assist with the investigation. During the course of the investigation, LPA interviewed four staff and other witnesses and obtained pertinent staff records such as the Resident Roster, Personnel Report Summary, Photo Identification for all staff, Personnel Records, 2024 Caregiver's Training Records, and CPR/First Aid Certificates.

The investigation revealed the following: It is alleged that the licensee falsified staff records. In review of the CPR/First Aid Certificates for five out of the five staff, all certificates are considered valid per the e-Verify system via the National CPR Foundation website.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20240917153724
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: RUBY COTTAGE
FACILITY NUMBER: 306006164
VISIT DATE: 09/24/2024
NARRATIVE
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Interviews conducted with four staff, all confirmed completing the required annual training and confirmed the training records were not falsified. Mandated Reporter trainings were covered under the Dementia and Residents Rights topics which was verified by Administrator Venus Bravo.

Therefore, based on the interviews which were conducted and the records that were reviewed, 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 following allegation: Licensee falsified staff records is deemed UNSUBSTANTIATED.

An exit interview was conducted with Administrator Venus Bravo and House Manager Arnold Bravo, and a copy of this report was provided at exit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20240917153724
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: RUBY COTTAGE
FACILITY NUMBER: 306006164
VISIT DATE: 09/24/2024
NARRATIVE
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Per review of the 2024 training records, three out of the three staff completed 31 out of the 20 training hours required. Regarding the two former caregivers, who were temporarily working at this facility as relievers, LPA verified per training records both completed their 40 hour annual training in 2022 at another facility operated by the same licensee. Interviews conducted with the current three caregivers, three out of three reported attending and completing the trainings per records. Interviews conducted with residents, one out of the six residents confirmed observing the trainings on site while the remaining residents did not recall and/or observe due to medical conditions.

It is alleged that the licensee did not ensure facility has a certified administrator. The administrator's certificate for Venus Bravo expired on August 4, 2024 and on May 13, 2023 for Arnold Bravo. Per review of the Certificate of Completion dated May 31, 2024, Venus Bravo completed the coursework and submitted the renewal documents to the Department around June 2024 as noted in the email correspondence. Facility has not received the current certificate due to a back log in issuing certificates by the Department. Administrator has completed all required coursework. Administrator stated that Arnold Bravo will not be renewing their certificate and is acting as the House Manager.

Therefore, this agency has investigated the complaint and based on the observations made, interviews which were conducted, and the records that were reviewed, the following allegations: Licensee did not ensure staff completed required training hours and Licensee did not ensure facility has a certified administrator are deemed UNFOUNDED. We have found that the complaint was unfounded, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

An exit interview was conducted with Administrator Venus Bravo and House Manager Arnold Bravo, and a copy of this report was provided at exit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4