306006270-4-17-2025-22-AS-LMOA-DG8VJF-20250430162841

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006270
Report Date: 04/17/2025
Date Signed: 04/17/2025 09:05:53 AM

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
04/09/2025 and conducted by Evaluator Jessica Cho

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20250409144044

FACILITY NAME:	IRVINE COTTAGE #7		FACILITY NUMBER:	306006270
ADMINISTRATOR:	ARNETT, KIMBERLY		FACILITY TYPE:	740
ADDRESS:	40 CYPRESS TREE LANE		TELEPHONE:	(949) 533-5938
CITY:	IRVINE	STATE: CA	ZIP CODE:	92612
CAPACITY:	6	CENSUS: 5	DATE:	04/17/2025
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Jozef Springer- Exeuctive Administrator		TIME COMPLETED:	09:20 AM

ALLEGATION(S):

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Staff did not seek medical attention for resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of delivering the findings into the above allegation for the complaint investigation. LPA was greeted and granted entry by Caregiver Jesus Abad and stated the purpose of the visit. Executive Administrator (EA) Jozef Springer was informed of the visit by telephone at 8:08am and arrived on premise at 8:45am. During the course of the investigation, LPA interviewed four staff, successfully interviewed one out of five residents, family member, and obtained pertinent documents such as the Face Sheets, Physician's Reports, Pre-Appraisal, Emergency Consent Form, Discharge Summary, Photos, Vital Records, Correspondences, and Call Log History.

Regarding the allegation, Staff did not seek medical attention for resident, it is alleged that the facility did not assess resident after the fall to ensure no further injury was sustained. The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

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 22-AS-20250409144044

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 #7	FACILITY NUMBER: 306006270
	VISIT DATE: 04/17/2025

NARRATIVE

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On Saturday, March 22, 2025, Resident #1 (R1) had a fall in their bedroom at or approximately 6am verified by R1. As a result of the fall, R1 sustained a small one inch laceration to the right brow bone region per the hospital discharge summary dated March 24, 2025. Three out of the four staff interviewed indicated conducting a fall assessment, taking vitals, and administering first aid to the wounded area immediately. The photograph demonstrates R1 with a band aid applied by the facility while the second photograph shows R1 with steri strips applied by the hospital which was noted on the discharge summary. R1 also confirmed facility staff treating the wound the day of the fall. In an interview with EA, there was not an immediate need to call 9-1-1 based on the assessment and R1 not showing/expressing any signs of pain. EA indicated that R1's representative was immediately notified by telephone following the fall. Based on the review of the call log screen shot, EA placed the call to R1's representative and left a voice message the day of the fall at 6:32am. The outgoing call was for 6 minutes. EA indicated that at 6:48am, the call was returned the same day by R1's representative and discussed R1's condition and vitals for four minutes. EA indicated that R1's representative was asked if they wanted R1 to be taken to the emergency room, even though EA did not believe the injury required immediate medical attention. EA indicated that the representative declined.

Due to conflicting information obtained during the investigation, 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: Staff did not seek medical attention for resident is deemed UNSUBSTANTIATED.

An exit interview was conducted with Executive Administrator Jozef Springer, and a copy of this report including the LIC811 were provided at exit.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

LIC9099 (FAS) - (06/04)

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