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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607071
Report Date: 02/03/2025
Date Signed: 02/03/2025 11:47:35 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/19/2024 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241119143625
FACILITY NAME:CHLOIE'S COTTAGEFACILITY NUMBER:
197607071
ADMINISTRATOR:LINDA RENARDFACILITY TYPE:
740
ADDRESS:747 N. BELLEVIEW AVENUETELEPHONE:
(909) 599-3193
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:6CENSUS: 6DATE:
02/03/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Staff Maria BlancoTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff do not have fingerprint clearance
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unnannounced subsequent complaint investigation visit for the allegation listed above. LPA met with Staff Maria Blanco and the purpose of the visit was discussed.

As of today, LPA has completed the following: LPA has toured the physical plant, Interviewed staff #1-4 (S1-S4), interviewed residents #1-6 (R1-R6), interviewed witnesses #1-2 (W1-W2), collected copies of the residents roster, staff roster, and collected copies of resident and staff files pertaining to the allegations. Staff #5 (S5) is not an employee at this time as was unavailable for interview. The investigation revealed the following:

Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025
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 9
Control Number 28-AS-20241119143625
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CHLOIE'S COTTAGE
FACILITY NUMBER: 197607071
VISIT DATE: 02/03/2025
NARRATIVE
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In regards to the allegation "Staff do not have fingerprint clearance" it was alleged that S5 worked at this facility without fingerprint clearance. (4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Staff interviews stated S5 did work one (1) day at the facility. It was an emergency and due to staff shortage S5 worked. S5 did not return to work at this facility any longer. The exact date was not provided to LPA. Staff was not able to provide LPA fingerprint clearance for S5. Interview stated it is possible S5 had an exempted clearance for working at another facility but was not able to provide that to LPA. This shows the facility failed to verify S5 fingerprint clearance prior to having S5 work at the facility. Based on LPA observations, interviews conducted and record review, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 1), are being cited on the attached LIC 9099D.

An exit interview was conducted. A copy of this report, Plan of Correction, and appeal rights were discussed and provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 28-AS-20241119143625
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CHLOIE'S COTTAGE
FACILITY NUMBER: 197607071
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/04/2025
Section Cited
CCR
87355(e)(1)
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87355. Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department
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S5 no longer works in the faciltiy. POC cleared at the time of this visit.
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This was not met as evidenced by: S5 working 1 day at the facility prior to
fingerprint clearance being verified or obtained. This poses an immediate health and safety risk to residents 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: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/19/2024 and conducted by Evaluator Jose Villalobos
COMPLAINT CONTROL NUMBER: 28-AS-20241119143625

FACILITY NAME:CHLOIE'S COTTAGEFACILITY NUMBER:
197607071
ADMINISTRATOR:LINDA RENARDFACILITY TYPE:
740
ADDRESS:747 N. BELLEVIEW AVENUETELEPHONE:
(909) 599-3193
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:6CENSUS: 6DATE:
02/03/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Staff Maria BlancoTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Residents are being sexually abused in the facility and staff do not intervene
Staff consume liquor while on shift
Staff lock facility doors to prevent residents from leaving
Staff insert suppositories to residents in care
Staff did not complete required trainings
Staff facility records are falsified
Staff did not maintain resident records
Staff do not ensure residents are provided with adequate food and food service
Staff are not providing residents with adequate care and supervision to meet the residents needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unnannounced subsequent complaint investigation visit for the allegation listed above. LPA met with Staff Maria Blanco and the purpose of the visit was discussed.

As of today, LPA has completed the following: LPA has toured the physical plant, Interviewed staff #1-4 (S1-S4), interviewed residents #1-6 (R1-R6), interviewed witnesses #1-2 (W1-W2), collected copies of the residents roster, staff roster, and collected copies of resident and staff files pertaining to the allegations. Staff #5 (S5) is not an employee at this time as was unavailable for interview. The investigation revealed the following:

Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025
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 9
Control Number 28-AS-20241119143625
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CHLOIE'S COTTAGE
FACILITY NUMBER: 197607071
VISIT DATE: 02/03/2025
NARRATIVE
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In regards to the allegation "Residents are being sexually abused in the facility and staff do not intervene" it is alleged that dementia residents are sexually molested by other residents and staff do not intervene. LPA was provided a name but the person named is not a resident or staff of the facility. (4) of (4) Staff denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Residents interviewed denied any sexual abuse and were not aware of that occurring in this home. Staff denied ever hearing of any sexual abuse incidents in the home and were not aware of it ever happening. File review does not show any documents on file related to the allegation.

In regards to the allegation "Staff consume liquor while on shift" it is alleged staff drink alcohol while on shift. (4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Staff interviewed denied drinking alcohol on shift and denied knowledge of anyone drinking alcohol in the facility. Residents interviewed were not aware of any staff drinking on shift. LPA did not observe any alcohol in the facility. LPA was not provided further information regarding which staff drink on shift.

In regards to the allegation "Staff lock facility doors to prevent residents from leaving" it is alleged night staff place locks high on the doors so they can sleep and prevent the residents from leaving the facility. (4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Residents denied having issues with leaving the facility when they want to and denied knowledge of observing staff sleeping while on shift. LPA's did not observe locks placed high on the facility doors. There were no door locks observed to be used to prevent residents from leaving their rooms or the facility.

In regards to the allegation "Staff insert suppositories to residents in care" it is alleged staff insert suppositories into residents and are not trained to. (4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Staff stated there are no residents who require suppositories and if they did, it would be a procedure done by a certified nurse. Residents interviewed denied needing a suppository at any point while being in the facility. LPA reviewed residents medication files and did not observe any prescribed suppository medication.

In regards to the allegation "Staff did not complete required training" it is alleged facility staff do not have training. (4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Staff interviewed were able to describe the training they complete yearly as caregivers. LPA reviewed training documentation on file and observed staff training to be completed per title 22 regulations. Residents interviewed stated to not have issues with the staff regarding their duties.
CONTINUED ON LIC 9099-C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 28-AS-20241119143625
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CHLOIE'S COTTAGE
FACILITY NUMBER: 197607071
VISIT DATE: 02/03/2025
NARRATIVE
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In regards to the allegation "Staff facility records are falsified" it is alleged staff have fake CPR training cards and health screenings. (4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Staff interviewed denied falsifying any documents. Residents were not able to provide any information regarding staff files. LPA reviewed staff CPR certificates on file to be in order. Health screening documents for staff on file were also completed as required by Title 22 Regulations. LPA was not provided with proof that any records were falsified.

In regards to the allegation "Staff did not maintain resident records" it is alleged that residents do not have current physicians reports and resident rosters on file. (4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Staff interviewed stated resident physicians are kept up to date and any changes are documented. LPA reviewed all resident physicians report on file to be completed within the last year. Resident roster was also reviewed. File review showed resident records to be maintained.

In regards to the allegation "Staff do not ensure residents are provided with adequate food and food service" it is alleged the facility staff does not purchase enough food for the residents. (4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Staff interviewed stated groceries are purchased weekly. There has been no shortage of food in the home. Residents were not aware of any shortage of food in the facility. LPA observed the facilities food supply to be adequate.

In regards to the allegation "Staff are not providing residents with adequate care and supervision to meet the residents needs" it is alleged that staff are not meeting residents grooming and toileting needs.(4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Residents interviewed did not show there was an issue with their grooming or toileting needs not being met. Staff stated they provide assistance to residents daily and anytime they request it. LPA observed staff assisting residents in care throughout the visits. File review showed that the care residents received match the needs and services plan.

Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegation(s). Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation(s) are UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/19/2024 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241119143625

FACILITY NAME:CHLOIE'S COTTAGEFACILITY NUMBER:
197607071
ADMINISTRATOR:LINDA RENARDFACILITY TYPE:
740
ADDRESS:747 N. BELLEVIEW AVENUETELEPHONE:
(909) 599-3193
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:6CENSUS: 6DATE:
02/03/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Staff Maria BlancoTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not inform resident’s physician of resident’s change of condition
Staff did not provide adequate medication assistance to residents in care
Staff refuse to call an ambulance for residents in care
Staff threaten and yell at residents in care
Centrally stored medications are accessible to residents in care
Staff do not have a fire evacuation plan at the facility
Staff do not have an infection control plan at the facility
Staff are not following reporting requirements
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unnannounced subsequent complaint investigation visit for the allegation listed above. LPA met with Staff Maria Blanco and the purpose of the visit was discussed.

As of today, LPA has completed the following: LPA has toured the physical plant, Interviewed staff #1-4 (S1-S4), interviewed residents #1-6 (R1-R6), interviewed witnesses #1-2 (W1-W2), collected copies of the residents roster, staff roster, and collected copies of resident and staff files pertaining to the allegations. Staff #5 (S5) is not an employee at this time as was unavailable for interview. The investigation revealed the following:

Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 28-AS-20241119143625
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CHLOIE'S COTTAGE
FACILITY NUMBER: 197607071
VISIT DATE: 02/03/2025
NARRATIVE
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In regards to the allegation "Staff did not inform resident’s physician of resident’s change of condition" it is alleged residents have health conditions not addressed with their physicians. (4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. LPA was not provided with information as to which resident had a change in condition not addressed. Residents interviewed did not state there were any issues or changes in their health conditions not being addressed. Resident files were reviewed and needs and service plans were up to date.

In regards to the allegation "Staff did not provide adequate medication assistance to residents in care" it is alleged that staff do not provide the residents medications as prescribed. (4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Residents stated to be receiving their medications with no issue. Staff interviewed stated to be providing residents their medication as prescribed. LPA reviewed residents medications and did not observe any errors or missed medications.

In regards to the allegation "Staff refuse to call an ambulance for residents in care" it is alleged that when residents ask for ambulance assistance the staff refuse to call. (4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Residents interviewed denied that they have ever been refused ambulance assistance by staff when needed. The staff interviewed stated they will always call an ambulance when needed and have not denied residents that right.

In regards to the allegation "Staff threaten and yell at residents in care" it is alleged that staff yell and threaten residents when they ask for help. (4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Residents interviewed stated they have never been yelled at or threatened by staff. Staff interviewed denied ever yelling or threatening any of the residents in care. LPA did not observe staff speaking inappropriately to residents in care during the visits.

In regards to the allegation "Centrally stored medications are accessible to residents in care" it is alleged that the key for the locked medication is out in the open where residents can grab it. (4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Residents interviewed were not aware of where the key to the locked medications was kept only that staff had access to them. Staff denied that the keys for the medication cabinet are out in the open. A staff on shift will carry the keys everyday. LPA observed the medication was locked in a cabinet and the staff had the key. The key was not accessible to residents in care.
Continued on LIC 9099-C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 28-AS-20241119143625
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CHLOIE'S COTTAGE
FACILITY NUMBER: 197607071
VISIT DATE: 02/03/2025
NARRATIVE
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In regards to the allegation "Staff do not have a fire evacuation plan at the facility" it is alleged that the facility does not have an evacuation plan in place in case of emergency.(4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Staff interviewed stated there is an emergency disaster plan in place that includes an evacuation plan for any emergency. LPA reviewed the emergency disaster plan on file.

In regards to the allegation "Staff do not have an infection control plan at the facility" it is alleged the facility does not have a completed infection control plan. (4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Staff interviewed stated there is a completed infection control plan in place and procedures to follow if needed. LPA was provided an infection control plan and it was reviewed during the visit. The facility did have a completed infection control plan.

In regards to the allegation "Staff are not following reporting requirements" it is alleged that Incident reports are falsely written and not all incidents are reported. (4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. LPA was not provided with specific dates or incidents not being reported correctly.

Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegation(s). Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation(s) are UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025
LIC9099 (FAS) - (06/04)
Page: 9 of 9