565850074-10-28-2025-29-AS-KLOZ-DNSNZ2-20251126095336

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850074
Report Date: 10/28/2025
Date Signed: 10/28/2025 01:30:15 PM

Unsubstantiated

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 INN		FACILITY NUMBER:	565850074
ADMINISTRATOR:	DANIA FAYYAD		FACILITY TYPE:	740
ADDRESS:	191 WAYVIEW CT		TELEPHONE:	(805) 650-7497
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY:	6	CENSUS: 4	DATE:	10/28/2025
		UNANNOUNCED	TIME BEGAN:	10:22 AM
MET WITH:	Judith Gonzalez		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Resident sustained a fracture while in care.
Resident sustained an unexplained bruise.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced follow-up complaint investigation visit at the facility at 10:22 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.

On 01/17/2025 the Woodland Hills North Adult and Senior Care Regional Office (RO) received a complaint alleging that resident #1 (R1) sustained a fracture while in the care of the facility. The case was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Laura Garcia. On 01/22/2025 between 10:30 AM and 01:30 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. On 03/27/2025 between 10:35 AM and 01:45 PM LPA Byrne conducted a physical plant tour, interviewed Staff #1 (S1) and Staff #2 (S2), three (3) residents, conducted a medication review for four (4) residents, and collected copies of pertinent documentation.

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025

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-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: 10/28/2025

NARRATIVE

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On 02/03/2025 at approximately 04:50 PM IB Investigator Garcia interviewed Witness #1 (W1). On 02/13/2025 at approximately 10:30 AM, Investigator Garcia interviewed the facility Administrator. On 02/14/2025 medical records pertaining to R1’s hospitalization were obtained. On 02/25/2025 at approximately 08:30 AM R1’s medical records were reviewed. On 03/06/2025 at approximately 11:30 AM IB reviewed additional records. On 03/11/2025 at approximately 04:30 PM IB completed the review of R1’s medical records. On 03/11/2025 at approximately 12:05 PM Investigator Garica interviewed S1. On 03/11/2025 at approximately 01:00 PM Investigator Garcia interviewed one (1) staff member. On 03/11/2025 at approximately 01:30 PM Investigator Garcia interviewed Resident #1 (R1). On 03/20/2025, 03/26/2025, and 04/08/2025 the Investigator attempted to contact Staff #3 (S3) with no response, voicemails were left. On 05/03/2025 the Investigator made contact and interviewed S3. On 06/03/2025 the Investigator conducted a follow-up interview with one (1) witness. On 06/04/2025 the Investigator interviewed R1’s physician.

During today’s visit LPA Byrne conducted a physical plant tour, interviewed two (2) staff, two (2) residents, and two (2) witnesses, and collected copies of pertinent documentation between 10:22 AM and 12:56 PM.

The allegation of “Resident sustained a fracture while in care.” Alleges that due to Neglect/ Lack of Care R1 sustained a fracture while under the care of the facility. During the course of the investigation, interviews were conducted with resident’s responsible party (W1), resident primary physician (W2), Facility Administrator, caregivers, and residents. Additionally, the medical records from the Hospital where R1 was treated were obtained and reviewed. According to Staff #3 (S3) who initially assisted R1 on the date of the incident, on 09/24/2024 at approximately 0800 hours, R1 was found by their commode on the floor. Staff immediately evaluated R1 for any injuries, pain or swelling. Staff did not observe any injuries, swelling or redness. R1 reported no pain and no discomfort. S3 stated that R1 mentioned that R1 only bumped their head but reported they were “okay”. R1 refused to seek medical attention or go to the hospital. Since R1 was not expressing any type of pain, staff continued to monitor the resident for the following 24-48 hours. Per the staff, R1 was closely monitored for any change in condition. Additionally, they were continuously observed ambulating utilizing a walker and continued having no pain. On 09/26/2024, it was noted that W1, came to visit R1 and subsequently took R1 out of the facility. Later that day, facility staff stated they received a call/texts messages from W1 advising that R1 was not feeling well and that they were taking R1 to the hospital because they had an accident when they were trying to put R1 inside the car and R1 was complaining of pain.

CONTINUED ON LIC 9099C.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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: 10/28/2025

NARRATIVE

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IB reviewed R1’s medical records which concluded the following conditions: Lumber levoscoliosis with asymmetric multilevel advanced disc degeneration and facet spondylosis with multilevel central canal stenosis. Mild chronic stable compression fracture deformity. Nondisplaced fracture of the right inferior pubic ramus, mild deformity left inferior pubic ramus which most likely represents old, healed injury and degenerative changes of the hips and sacroiliac joints. Upon conducting research on these conditions IB determined that the conditions pose a higher risk of subsequent fractures in the elderly. Based on the above information and documentation provided, there is insufficient evidence to support when and how the fracture was sustained. Therefore, IB found the allegation of “Resident sustained a fracture while in care” due to neglect/ Lack of Care of Cottage Inn to be deemed “unsubstantiated” at this time.

The allegation of “Resident sustained an unexplained bruise.” Alleges that R1 sustained an unexplained bruise on their forehead in early January 2025 while in the care of the facility. LPA interviewed W1 who described the bruise on R1’s forehead as 1-1 1/2 inch deep black and blue round/circular bruise. W1 was unable to provide LPA with photographic evidence of the bruise. LPA conducted a review of R1’s medications for December 2024 and January 2025. LPA observed four (4) medications on R1's Medication Administration Record (MAR) that had indicated side effects of “unusual bleeding and bruising”. LPA interviewed Staff #1 (S1), former staff #3 (S3), and staff #4 (S4). All staff interviewed denied observing a bruise on R1’s body during their stay at the facility in January 2025. LPA interviewed two (2) residents of the facility. Both residents interviewed stated that staff treat them well and that staff handle them gently while assisting in their care. Both residents had no concerns with the quality of care they received at the facility. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of “Resident sustained an unexplained bruise.” Therefore the allegation deemed to be “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: 10/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025

LIC9099 (FAS) - (06/04)

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