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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603738
Report Date: 09/22/2022
Date Signed: 09/22/2022 04:27:41 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/14/2022 and conducted by Evaluator Kayla Hilario
COMPLAINT CONTROL NUMBER: 08-AS-20220114132002
FACILITY NAME:NORTH COUNTY COTTAGEFACILITY NUMBER:
374603738
ADMINISTRATOR:MARI DEE SANDRA CIDFACILITY TYPE:
740
ADDRESS:221 W 6TH AVETELEPHONE:
(760) 743-7133
CITY:ESCONDIDOSTATE: CAZIP CODE:
92025
CAPACITY:13CENSUS: 11DATE:
09/22/2022
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Caregiver Gil OrtegaTIME COMPLETED:
02:05 PM
ALLEGATION(S):
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Unlawful eviction.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Kayla Hilario, conducted an unannounced visit to deliver findings regarding the above-mentioned allegation. LPA was allowed entry, discussed the purpose of the visit, and met with Caregiver Gil Ortega. LPA spoke with Administrator Mari Dee Sandra Cid via telephone and discussed the purpose of the visit and findings.

The Department’s investigation included a tour of the facility, observations, records reviews, and interviews with staff and outside sources. Prior to the investigation, LPA interviewed the reporting party and reviewed the facility file.

It was alleged that the licensee unlawfully evicted Resident #1 (R1). [See LIC 811 Confidential Names List for a description of R1]. On 01/12/2022, R1 was sent to the hospital for evaluation of change in condition. While there, resident tested positive for COVID-19. Resident was medically cleared to return to
***Continued on 9099c***This is an amended version of the original report to include signatures.***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Kayla Hilario
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
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 08-AS-20220114132002
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: NORTH COUNTY COTTAGE
FACILITY NUMBER: 374603738
VISIT DATE: 09/22/2022
NARRATIVE
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the facility on 01/13/2022. Facility staff admittedly refused to allow resident to return to the facility as they reported there was no private isolation room available. Hospital staff corroborated that resident was ready to return to the facility on 01/13/2022 and that R1 no longer met the criteria to be hospitalized. After discussion with a licensing program manager, facility staff arranged an isolation room and planned for the return of R1 to the facility on 01/14/2022. The licensee’s violation was in preventing R1’s discharge back to the facility following medical clearance. Licensee did not serve R1 with either a 30-day notice or a 3-day notice to quit as required by law, nor did the licensee have a valid reason to issue an eviction. California Department of Social Services, Community Care Licensing Division (CCLD), Adult and Senior Care Program, Provider Information Notice (PIN) 20-38 ASC, page seven (7) states that, “Licensees who have difficulties with accepting returned residents who are confirmed COVID-19 positive from a hospital or SNF, should immediately contact the Regional Office and local health department before the resident’s return.” Facility staff did not seek guidance on the return of R1 until the issue was elevated by an outside source.

Based on observation, interviews with staff and outside sources, and review of records, a preponderance of evidence exists to substantiate the allegation. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was discussed and reviewed with Administrator Mari Dee Sandra Cid via telephone. An exit interview was conducted with caregiver Gil Ortega to whom a copy of this report, the Confidential Names list (LIC811), PIN 20-38, and the Licensee/Appeal Rights (LIC9058 03/22) were provided via hardcopy at the conclusion of the visit.

***This is an amended version of the original report to include signatures.***
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Kayla Hilario
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20220114132002
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: NORTH COUNTY COTTAGE
FACILITY NUMBER: 374603738
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/27/2022
Section Cited
CCR
87224(a)
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87224 Eviction Procedure: (a) The licensee may evict a resident… Thirty (30) days written notice to the resident is required…This requirement was not met as evidenced by:
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Licensee shall review the regulation in its entirety, conduct training to staff, and submit a letter verifying that the regulation is understood by all. Verification to be placed on letterhead, with the training provided, and staff in attendance. Licensee shall submit to letter to LPA by Tuesday 09/27/2022.
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Based on facility documents and interviews with staff and outside sources, facility staff admittedly did not comply with the Eviction Procedures for 1 of 11 residents. This posed a potential health and safety risk to residents in care.
***This is an amended version of the oringinal report to include signatures.***
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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: John Rante
LICENSING EVALUATOR NAME: Kayla Hilario
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3