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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850074
Report Date: 03/27/2025
Date Signed: 03/27/2025 02:36:19 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
01/17/2025 and conducted by Evaluator Trevor Byrne
COMPLAINT CONTROL NUMBER: 29-AS-20250117165236
FACILITY NAME:COTTAGE INNFACILITY NUMBER:
565850074
ADMINISTRATOR:DANIA FAYYADFACILITY TYPE:
740
ADDRESS:191 WAYVIEW CTTELEPHONE:
(805) 650-7497
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:6CENSUS: 4DATE:
03/27/2025
UNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Judith GonzalezTIME COMPLETED:
01:51 PM
ALLEGATION(S):
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9
Staff did not provide adequate supervision resulting in resident leaving the facility.
Staff did not answer resident's call button in a timely manner.
Staff did not ensure resident's showering needs were being met.
INVESTIGATION FINDINGS:
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5
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13
Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced follow-up complaint investigation visit at the facility at 10:33 AM. LPA met with facility staff who contacted the Administrator Dania Fayyad via telephone call. The Administrator was unavailable to come to the facility at the time of the visit. LPA explained the reason for the visit to Judith Gonzalez (S1) and entrance interview was conducted.

During the initial complaint visit on 01/22/2025 between 10:30 AM and 1:30 PM, LPA Cortez toured the physical plant, interviewed the Administrator, one (1) staff, conducted a file review, and obtained copies of resident records and other pertinent documents relevant to the investigation. During today’s visit LPA Byrne conducted a physical plant tour, interviewed two (2) staff, three (3) residents, conducted a medication review for four (4) residents, and collected copies of pertinent documentation between 10:35 AM and 01:45 PM.

Continued on LIC-9099C
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025
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 8
Control Number 29-AS-20250117165236
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COTTAGE INN
FACILITY NUMBER: 565850074
VISIT DATE: 03/27/2025
NARRATIVE
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The allegation of “Staff did not provide adequate supervision resulting in resident leaving the facility.” alleges that the facility did not have functioning auditory alarms or adequate staff supervision to prevent resident #1 (R1) from leaving the facility unassisted. During the initial complaint investigation on 01/22/2025 LPA Cortez observed the front door and the sliding glass door of the front living room to be equipped with auditory alarms. LPA observed these alarms to be non-functional when the doors were opened. Facility staff informed LPA that the alarms worked but were turned off. During today’s visit LPA Byrne observed the kitchen side door, the sliding glass door of the front living room, and the hallway sliding glass door to be equipped with auditory alarms that were in the off position. All three (3) Auditory alarms failed to alert when the doors were opened. LPA asked staff why the alarms were turned off, staff were unsure but believe that it may have been because of the gardeners working. Additionally, in the month of December R1 eloped from the facility grounds without the notification of an auditory alarm. Based on the information obtained during the physical plant tour and interviews there is sufficient evidence to support the allegation of “Staff did not provide adequate supervision resulting in resident leaving the facility.” Therefore, the allegation is deemed Substantiated at this time.

The allegation of “Staff did not answer resident's call button in a timely manner.” alleges that the facility staff did not answer R1’s call button in a timely manner. During interviews with residents, two (2) residents stated that staff have been slow/unresponsive in the past to their calls for assistance. Resident #2 (R2) stated that facility staff have silenced their call button before after attempts to notify staff that they need assistance. LPA pressed the call button for R2 during the interview at 10:56 AM. At the time of the button press LPA attempted to listen for a chime but was unable to hear any notification that a call button was pressed. LPA waited 15 minutes until 11:11 AM and no staff responded to the call button press. LPA asked S1 for the reason the call button was not answered. S1 stated that they must have not heard the notification and denied that resident call buttons are ever silenced. At approximately 12:50 PM LPA asked staff #2 (S2) to press the resident’s call button. When this button was pressed LPA observed the alarm to go off. S2 confirmed that R1, while they resided at the facility, had a call button to notify staff that they required assistance. Staff denied ever missing a call button notification and S1 reiterated that their average response time to resident’s requests for assistance does not exceed seven (7) minutes. Based on the information obtained during the physical plant tour and interviews there is sufficient evidence to support the allegation of “Staff did not answer resident's call button in a timely manner.” Therefore, the allegation is deemed Substantiated at this time.
Continued on LIC 9099C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 29-AS-20250117165236
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COTTAGE INN
FACILITY NUMBER: 565850074
VISIT DATE: 03/27/2025
NARRATIVE
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The allegation of “Staff did not ensure resident's showering needs were being met.” alleges that the facility staff were not showering R1 on an appropriate basis. Interviews with two (2) residents revealed that they feel like facility staff are not showering/bathing them enough. One (1) resident stated that they have asked staff for a shower previously and were told that staff would do it later in the day. The resident stated that staff “Blew them off” and never returned to shower them. One (1) resident interviewed stated that they had gone a month without a shower. LPA interviewed staff members who stated that resident’s showers are on a schedule and are given 2-3 times per week. Both staff interviewed denied skipping resident’s showers unless the resident refused. S2 stated that some residents have refused showers this month and it is logged in the shower binder. LPA observed the shower log for the month of March. LPA observed one resident to have a shower that was not given according to the schedule. One resident confirmed that they had not been getting showers on the dates that were logged in the binder. Based on the information obtained during interviews and file review there is sufficient evidence to support the allegation of “Staff did not ensure resident's showering needs were being met.” Therefore, the allegation is deemed Substantiated at this time.

The following deficiencies were cited (refer to LIC 9099D). The Administrator was unavailable to come to the facility at the time of this inspection but has designated S1 to sign on their behalf. Report was read to the Administrator via telephone call. Exit interview conducted and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
01/17/2025 and conducted by Evaluator Trevor Byrne
COMPLAINT CONTROL NUMBER: 29-AS-20250117165236

FACILITY NAME:COTTAGE INNFACILITY NUMBER:
565850074
ADMINISTRATOR:DANIA FAYYADFACILITY TYPE:
740
ADDRESS:191 WAYVIEW CTTELEPHONE:
(805) 650-7497
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:6CENSUS: 4DATE:
03/27/2025
UNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Judith GonzalezTIME COMPLETED:
01:51 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not follow medical directions for resident's medical needs.
Staff did not provide resident adequate food meals.
INVESTIGATION FINDINGS:
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2
3
4
5
6
7
8
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10
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12
13
Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced follow-up complaint investigation visit at the facility at 10:33 AM. LPA met with facility staff who contacted the Administrator Dania Fayyad via telephone call. The Administrator was unavailable to come to the facility at the time of the visit. LPA explained the reason for the visit to Judith Gonzalez (S1) and entrance interview was conducted.

During the initial complaint visit on 01/22/2025 between 10:30 AM and 1:30 PM, LPA Cortez toured the physical plant, interviewed the Administrator, one (1) staff, conducted a file review, and obtained copies of resident records and other pertinent documents relevant to the investigation. During today’s visit LPA Byrne conducted a physical plant tour, interviewed two (2) staff, three (3) residents, conducted a medication review for four (4) residents, and collected copies of pertinent documentation between 10:35 AM and 01:45 PM.

Continued on LIC 9099C.
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 29-AS-20250117165236
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COTTAGE INN
FACILITY NUMBER: 565850074
VISIT DATE: 03/27/2025
NARRATIVE
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The allegation of “Staff did not follow medical directions for resident's medical needs.” alleges that the facility staff did not follow medical directions prior to a uranalysis appointment for R1 and that facility staff did not assist in the proper storage of a urinalysis sample. LPA interviewed S1 who recalled the incident with R1’s urine sample. S1 stated that R1 had utilized the restroom prior to their scheduled urinalysis appointment. LPA interviewed Witness #1 (W1) who corroborated this statement. As R1 was unable to urinate at the time of their appointment they were given a sample collection cup to submit at a later date. S1 stated that they had R1 urinate in the sample cup the next day but the staff member assisting R1 got distracted by a call from another resident and left the sample on the counter of the bathroom. S1 stated that R1 took the cup and poured the sample into the toilet. W1 stated that they arrived to the facility to take R1 to drop off the sample and staff were trying to have R1 produce another sample. W1 stated that they told staff to take care of submitting the sample and did not believe R1 would pour out the sample. LPA confirmed with S1 and W1 that a sample was submitted to the lab the same day. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Staff did not follow medical directions for resident's medical needs.” Therefore, the allegation is deemed Unsubstantiated at this time

The allegation of “Staff did not provide resident adequate food meals.” alleges that the facility staff did not provide R1 with nutritious meals. Interviews with three (3) residents revealed that the facility serves enough food to the residents in care. Interviews with staff revealed that the facility offers a variety of foods to residents and accommodations are made if residents do not want what is being served. LPA observed the facility to have adequate amounts and variety of foods to be served to residents. LPA observed the portions of food being served to residents at 01:47 PM and observed the portions to be adequate. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Staff did not provide resident adequate food meals.” Therefore, the allegation is deemed Unsubstantiated at this time.

The Administrator was unavailable to come to the facility at the time of this inspection but has designated S1 to sign on their behalf. Report was read to the Administrator via telephone call. Exit interview conducted and a copy of the report was provided.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 29-AS-20250117165236
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COTTAGE INN
FACILITY NUMBER: 565850074
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/10/2025
Section Cited
CCR
87705(d)
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87705 Care of Persons with Dementia
(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates...
This requirement is not met as evidenced by:
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Licensee will submit a statement of understanding confirming that they understand the importance of auditory alarms being turned on while staff is not actively monitoring the exit. Additionally, Licensee will submit proof of all exits being equipped with functioning auditory alarms by POC due date.
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Based on observation the licensee did not comply with the section cited above as exit doors throughout the facility were observed to be equipped with auditory alarms that were turned off and did not alert when opened which poses a potential safety risk to clients in care.
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Type B
04/10/2025
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights...
(a) In addition to the rights...
(4) To..services that meet their individual needs...
This requirement is not met as evidenced by:
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Licensee will submit proof that all call buttons are operable, and will submit a statement of understanding confirming that staff will respond to resident's call buttons and ensure that call buttons are always operational and not turned off/silenced. Licensee will submit these corrections no later than POC due date.
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Based on observation and interview the licensee did not comply with the section cited above as a call button was pressed and no staff responded within a 15 minute timeframe which poses a potential health, safety, or personal rights risk to clients in care.
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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: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 29-AS-20250117165236
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COTTAGE INN
FACILITY NUMBER: 565850074
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/10/2025
Section Cited
HSC
1569.312(a)
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§1569.312 Basic services...
Every facility... shall provide at least the following basic services:
(a) Care and supervision as defined in Section 1569.2.
This requirement is not met as evidenced by:
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Licensee will submit their plan on how they will meet resident's showering needs. This plan may include residents signing off that they have received a shower or a similar method of tracking. Licensee will submit their plan to CCLD no later than POC due date.
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Based on interview and record review the licensee did not comply with the section cited above as multiple residents stated that their shower needs are not being met by staff which poses a potential health or personal rights risk to clients in care.
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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: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 8