195850184-6-10-2024-29-AS-KLOZ-D6NT98-20240628143131

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850184
Report Date: 06/10/2024
Date Signed: 06/10/2024 04:01:45 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
05/02/2024 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20240502114023

FACILITY NAME:	COTTAGES AT THE COLONY OF SHERMAN OAKS #4		FACILITY NUMBER:	195850184
ADMINISTRATOR:	LEE, ANNA B DELROSARIO		FACILITY TYPE:	740
ADDRESS:	5430 TYRONE AVENUE		TELEPHONE:	(818) 855-7021
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91401
CAPACITY:	6	CENSUS: 6	DATE:	06/10/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Anna Lee		TIME COMPLETED:	10:39 AM

ALLEGATION(S):

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Staff took inappropriate pictures of resident's body.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent complaint visit to deliver findings for the allegation listed above. LPA met with Administrator Anna Lee and explained the reason for the visit.
On 05/02/2024, the Department received a complaint regarding staff taking inappropriate pictures of Resident #1’s (R1) body. The complaint was referred to Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Heidy Bendana.

On 05/03/2024, from 9:55am to 11:45am, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced visit to investigate the allegation listed above. LPA Urena met with administrator Anna Lee and explained the reason for the visit. At 10:05am, the LPA interviewed the administrator, and at 10:30am the LPA requested and reviewed records pertinent to the complaint. The LPA advised the administrator that the case was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Heidy Bendana. Continues on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024

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-20240502114023

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: COTTAGES AT THE COLONY OF SHERMAN OAKS #4	FACILITY NUMBER: 195850184
	VISIT DATE: 06/10/2024

NARRATIVE

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Pg. 2
On 05/08/2024, from approximately 9:38am to 10:23am, Investigator Bendana conducted interviews with R1, the administrator and facility field supervisor (S1). In addition, the Investigator reviewed photographs and facility file documents related to R1.

A review of the Home Health Certification & Plan of Care for R1 listed the start date as 01/21/2023. Diagnosis included zoster (shingles), heart failure and chronic pain. R1 is a fall risk with limited ambulation. R1 is forgetful at times, needs prompting under stressful or unfamiliar conditions. R1’s Physician’s Report, dated 11/06/2023, lists the primary diagnosis as mild cognitive disorder and cerebral infraction with sequelae. R1 is listed to be confused/disoriented at times, depressed but can follow instructions. R1 requires assistance with Activities of Daily Living (ADLs) and is non-ambulatory. The Resident Appraisal for R1, dated 01/12/2024, documents R1 uses a walker and requires assistance and supervision during ambulation. R1 has periods of forgetfulness and confusion, has no interest in social activities, and is in bed most of the time.

A review of the Photo/Video Consent & Release document revealed that the photographs are not made part of the resident record. Photographs are periodically taken for internal or safety purposes, such as to be shared with medical personnel. Text printouts were reviewed, dated 03/12/2024 at 1:21pm, the administrator texted R1’s resident representative regarding photo and video consent forms. The administrator explained skin checks are done weekly and photos are used to document no skin issue. The form was signed 04/03/2024 by R1’s resident representative.

During the investigation, the administrator provided a printout of R1’s photographs taken. On 05/06/2024, at approximately 3:34pm hours, S1 conducted a skin check on R1. The skin check consisted of vitals. It is noted R1 had on and off pain in their legs and back. No skin breakdown noticed. Photographs of heel, feet, and bottom of both feet were taken. On 01/18/2024, at approximately 9:38am, S1 conducted a skin check on R1. The photographs are of R1’s torso and chest area affected by shingles. R1 is lifting R1’s top, nipples are not visible, R1’s face is not visible. Photograph is focused on the affected area.

Continues on LIC 9099 C...pg. 3

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20240502114023

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: COTTAGES AT THE COLONY OF SHERMAN OAKS #4	FACILITY NUMBER: 195850184
	VISIT DATE: 06/10/2024

NARRATIVE

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Pg. 3

The investigation further revealed, on 05/02/2024, at 3:11pm, the Los Angeles Police Department, Van Nuys Patrol Division officers responded to the facility due to a phone call from R1. A card was left indicating a report only was taken by law enforcement.

Based on the information obtained during the investigation, R1 stated they were not touched inappropriately by facility staff. R1 stated S1 conducts skin checks weekly to check for bed sores. Interviews and documents show skin checks are conducted weekly by S1. S1 asks and informs residents about photographs taken to document bed sores, shingles, or redness. The photographs taken were not sexual in nature. During the interview, R1 showed signs of confusion. Nevertheless, R1 felt safe in the facility. R1 disclosed they had previously refused photographs to be taken and S1 respected R1’s request. Documentation provided by the administrator, included a signed consent for photographs; signed by R1’s resident representative. Based on the information obtained and statements made, the Department did not find sufficient evidence to support the allegation that staff took inappropriate pictures of R1’s body. Therefore, the allegation “staff took inappropriate pictures of resident's body” is deemed Unsubstantiated at this time.

Exit interview conducted, copy of this report issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024

LIC9099 (FAS) - (06/04)

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