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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006258
Report Date: 03/12/2025
Date Signed: 03/12/2025 04:11:58 PM

Unsubstantiated


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
01/27/2025 and conducted by Evaluator Ruth Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250127132510
FACILITY NAME:IRVINE COTTAGE #3FACILITY NUMBER:
306006258
ADMINISTRATOR:ARNETT, KIMBERLYFACILITY TYPE:
740
ADDRESS:17 YORKTOWNTELEPHONE:
(949) 533-5938
CITY:IRVINESTATE: CAZIP CODE:
92620
CAPACITY:6CENSUS: DATE:
03/12/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Kim Arnett, AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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AM Facility staff are physical with resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegation. LPA arrive at facility was greeted and granted entry by caregiver. LPA spoke with Kimberly Arnett, Administrator and explained the purpose of the visit.

Findings are based upon this investigation which included resident file review, tour of the physical plant of the facility and interviews conducted. It is alleged AM facility staff are physical with resident. Interview with 2 of 2 staff stated that resident (R1) would often hit their arm in the bed rails when getting ready in the morning, at times got agitated with staff and R1 was on dialysis and medication for the blood which staff noticed R1 would bruise easy. Review of resident medication it was observed that R1 was taking Aspiring

Cotinued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
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 2
Control Number 22-AS-20250127132510
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: IRVINE COTTAGE #3
FACILITY NUMBER: 306006258
VISIT DATE: 03/12/2025
NARRATIVE
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and Renvela which can play a role in the bruising. Interview with 2 of 2 facility residents stated that they have never seen staff be aggressive or grab roughly towards any resident.

Based on the information mentioned above, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated.

An exit interview was conducted with Administrator and a copy of this LIC9099 report was left at facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2