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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801978
Report Date: 01/29/2025
Date Signed: 01/29/2025 12:55:44 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
12/11/2024 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 29-AS-20241211092619
FACILITY NAME:FAMILYCARE COTTAGE IVFACILITY NUMBER:
565801978
ADMINISTRATOR:DEBRA BRYANTFACILITY TYPE:
740
ADDRESS:825 CALLE CEDROTELEPHONE:
(805) 380-4108
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 4DATE:
01/29/2025
UNANNOUNCEDTIME BEGAN:
09:59 AM
MET WITH:Marisol FlamencoTIME COMPLETED:
01:05 PM
ALLEGATION(S):
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Licensee does not ensure facility is adequately staffed to meet resident's needs
Staff are not properly supervising residents who may be a fall risk
Staff did not prevent resident from wandering from facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation for the allegations listed above. LPA arrived at the facility at 09:59AM and initially met with facility staff. LPA indicated the reason for today's visit. Facility Designee Marisol Flamenco arrived shortly after the visit began. Entrance interview conducted.

During today's visit, LPA interviewed staff and residents between 10:02AM and 10:40AM and resident's family members at 11:03AM and 11:28AM. LPA also reviewed the current staff schedule. During an initial complaint visit conducted on 12/17/2024, LPA interviewed Designee at 12:10PM, toured the facility with Designee at 12:29PM, LPA took photographs of relevant areas, interviewed staff at 12:33PM, and LPA reviewed and obtained copies of pertinent documents. The following was then determined:

Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
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)
Page: 1 of 3
Control Number 29-AS-20241211092619
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 IV
FACILITY NUMBER: 565801978
VISIT DATE: 01/29/2025
NARRATIVE
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Allegation: "Licensee does not ensure facility is adequately staffed to meet residents' needs:"
LPA interviewed staff, residents, and family members and reviewed staff schedules related to this allegation. LPA noted that 1 (one) staff is scheduled for this facility at all times. Interview with staff revealed that during times when residents require showering, an additional staff comes from another of the licensee's facilities nearby and will assist the staff at this location. It was also noted that the licensee's office is located on this facility property, so during normal business hours Monday through Friday, the facility designee is present at this facility. Staff interviewed stated that either the facility designee or staff from the other facility cover breaks and assist in the facility as needed. Interview also revealed that when a new resident moves in, there are 2 (two) staff scheduled. Additionally, if a new resident moves in that has higher needs or behavioral expressions, the staff schedule is adjusted to meet resident needs. Interview revealed that the residents that reside at the facility at this time do not have unsafe wandering behaviors. Residents interviewed stated there is enough staff at the facility to meet their needs. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Allegation: "Staff are not properly supervising residents who may be a fall risk:"
The complaint alleges that during an undisclosed time, while staff was assisting a resident, another resident fell. LPA inquired with staff, residents, and facility designee related to falls. All persons interviewed stated there have been no falls at this location in some time. During both the initial visit and the subsequent visit, LPA observed residents in the facility to be seated in common areas or in their own rooms. LPA also observed residents self-ambulating during both visits. Staff indicated that 3 (three) of the 4 (four) residents are able to ambulate safely independently. 1 (one) resident does require an escort while ambulating, but staff are able to assist this resident. Additionally, the resident does have a motion alarm which alerts staff when the resident stands up to ensure this resident is assisted as needed. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.


Continued on LIC 9099-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
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)
Page: 2 of 3
Control Number 29-AS-20241211092619
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 IV
FACILITY NUMBER: 565801978
VISIT DATE: 01/29/2025
NARRATIVE
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Allegation: "Staff did not prevent resident from wandering from facility:"
The complaint alleges that a resident wandered out the front door while the staff was busy assisting another resident. LPA interviewed staff and facility designee, all of whom stated there are no current residents who engage in unsafe wandering. Staff stated there was a resident a long time ago that did attempt to elope from the facility, but that the facility designee did accompany the resident out the front door into the facility driveway before redirecting the resident inside. The resident was supervised at all times. LPA noted that the facility does have an auditory alarm on all exit doors, which were observed to be functional during both visits. Staff interviewed indicated that at times when they have had a resident that engages in unsafe wandering, there have been 2 (two) staff scheduled to ensure adequate supervision for the residents in care. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

No citations issued. Exit interview conducted with facility designee. A copy of today's report was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
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)
Page: 3 of 3