335530110-6-30-2025-56-AS-EMAN-DKYPJ8-20250828112106

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 335530110
Report Date: 06/30/2025
Date Signed: 06/30/2025 01:56:32 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/05/2025 and conducted by Evaluator Raquel Hernandez

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20250205133023

FACILITY NAME:	CATHY'S COTTAGE PALMS		FACILITY NUMBER:	335530110
ADMINISTRATOR:	BIRKINBINE, JULIE		FACILITY TYPE:	740
ADDRESS:	4221 SHOALCREEK DRIVE		TELEPHONE:	(951) 809-9571
CITY:	CORONA	STATE: CA	ZIP CODE:	92883
CAPACITY:	6	CENSUS: 5	DATE:	06/30/2025
		UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Assistant Administrator Elizabeth Gail		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Questionable death due to staff neglect.
Staff failed to respond to resident's call light.
Facility staff did not provide resident's records to responsible person.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Raquel Hernandez conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Assistant Administrator Elizabeth Gail and explained the purpose of the visit. The investigation conducted by Department staff consisted of staff interviews, resident interviews and document review.

Allegation: Questionable death due to staff neglect

The investigation did not provide sufficient evidence to corroborate the allegation of Questionable Death due to staff neglect. Resident 1 (R1) was admitted to Cathy’s Cottage Palms on December 3, 2024, after a history of falling at home. R1 was diagnosed with dementia and had an unsteady gait. R1 passed away on December 14, 2024, when R1 was found unresponsive by the caregiver with head wedged between the mattress and the bed rail.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025

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 56-AS-20250205133023

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CATHY'S COTTAGE PALMS	FACILITY NUMBER: 335530110
	VISIT DATE: 06/30/2025

NARRATIVE

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The coroner’s report indicated, Cause of death, as Positional Asphyxia with other significant conditions contributing to the death. Injury/Mode was categorized as accident. There were no other concerning or suspicious factors that contributed to R1’s death.

Allegation: Staff failed to respond to R1’s call light.

On December 14, 2024, R1 was found unresponsive by Staff 1 (S1) with head wedged between the mattress and the bed rail. On the day of the incident, S1 indicated she checked on R1 every two hours. At 0100 hours, S1 checked on R1 and R1 was observed to be asleep. At 0200 hours, S1 heard R1’s alarm sound and responded to R1’s room. S1 observed R1’s blankets were off and R1 was tossing and turning in bed. S1 put the blankets back on and left the room. Between 0330 and 0400 hours, R1’s alarm sounded again, and S1 responded to R1’s room within two minutes. S1 was assisting Resident 2 (R2) with a bowel movement. Once S1 responded, S1 found R1 to be unresponsive, kneeling on the floor with his head wedged between the mattress and the bedrail. There was insufficient evidence to corroborate that staff failed to respond to R1’s bed alarm in a timely manner.

Allegation: Facility staff did not provide resident's records to responsible person

LPA observed no formal request of resident records that are located at the facility. Administrator indicated R1’s records are provided to responsible party when requested, however, request of hospice documentation that is not located in resident's file, is directed to hospice agency.

Based on the evidence, there is insufficient evidence to corroborate the three allegations listed above. Therefore, the findings are UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted where this report (LIC9099) was discussed, and a copy was provided to Assistant Administrator Elizabeth Gail.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025

LIC9099 (FAS) - (06/04)

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