565801505-1-29-2025-29-AS-KBUY-DDG64L-20250131192855

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801505
Report Date: 01/29/2025
Date Signed: 01/29/2025 03:10:06 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/23/2024 and conducted by Evaluator Zabel Chochian

COMPLAINT CONTROL NUMBER: 29-AS-20240723124722

FACILITY NAME:	FAMILYCARE COTTAGE ONE		FACILITY NUMBER:	565801505
ADMINISTRATOR:	CHRISSY CORTEZ		FACILITY TYPE:	740
ADDRESS:	820 CALLE CEDRO		TELEPHONE:	(805) 492-1200
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 6	DATE:	01/29/2025
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Marisol Flamenco		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Resident developed maggot infested wound while in care of staff.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to the facility. The purpose of the visit is to deliver investigation finding. Upon arrival LPA met with Marisol Flamenco and explained the reason for the visit. Entrance interview conducted.

On 07/23/2024, Community Care Licensing Division (CCLD) received a complaint with the above allegation. Investigation was initiated on 08/02/2024; at approximately 9:45a.m., a physical plant tour was conducted with administrator. Resident and staff records were reviewed at approximately 10a.m. and interviews were conducted with staff at 11:30a.m. Pertinent documents were requested and received on 08/06/2024.

Following is a summary of the investigation finding:
Regarding allegation, “Resident developed maggot infested wound while in care of staff.” – It was alleged that due to improper wound care by staff, resident #1’s (R1) wound on the left side of the face was infested with maggots. (Continue to LIC9099c)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025

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 29-AS-20240723124722

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FAMILYCARE COTTAGE ONE	FACILITY NUMBER: 565801505
	VISIT DATE: 01/29/2025

NARRATIVE

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Records obtained from facility and Oakhurst Heritage Hospice was reviewed and revealed that R1 did not have an open wound. Records reviewed and interview conducted with hospice nurse revealed that R1 had a facial growth (quarter size) which was being treated by hospice and wound care specialist. Between the hospice nurse visit and wound care nurse R1 was seen three times a week;-twice a week from hospice and once a week by the wound care specialist.

According to administrator and staff they observed change in R1’s condition (wound/growth) and it was immediately reported, and medical attention was provided. Administrator and staff stated that it was not there duty to clean R1’s wound and they would only observe and report to hospice.

Interviews conducted confirmed that hospice and a wound care specialist was treating the growth on R1's face. Staff interviewed stated that R1’s wound was covered and only hospice would change the dressing. Records reviewed confirmed that R1 was last seen by hospice nurse on 07/17/2024; hospice notes reviewed indicated that R1’s growth was increasing in size and not getting better; however, there was no drainage noted. According to hospice nurse facility staff reported the incident immediately and were instructed to call 911. R1 was take to the hospital for further evaluation. According to hospice nurse facility staff did not provide any type of wound care.

Additional interviews were conducted during today's visit with potential witnesses regarding the facility staff care services. All interviewed reported being satisfied with the care services provided by the facility staff.

Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegation “Resident developed maggot infested wound while in care of staff.” is deemed UNSUBSTANTIATED at this time.

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025

LIC9099 (FAS) - (06/04)

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