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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607071
Report Date: 08/23/2025
Date Signed: 08/23/2025 12:43:24 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
08/20/2025 and conducted by Evaluator Tena Herrera
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250820121118
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:
08/23/2025
UNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:Iren Creighton - AdministratorTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff are locking and isolating a resident inside of the facility.
Staff are not allowing a resident to file complaints.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to investigate the above allegations. LPA met with Administrator Iren Creighton and explained the purpose of today's visit.

The investigation consisted of the following:

On 8/21/2025 LPA reviewed Medications and Medication Administration Record for 5 residents, Reviewed 5 Resident Files, interviewed 3 staff and 4 residents, LPA attempted to interview 2 additional residents, however, due to cognitive disabilities the interviews were not successful. LPA interviewed responsible party for Resident #1 prior to leaving facility.
During todays visit 8/23/2025 LPA delivered findings on the above allegations.

(continued on the LIC9099-C page)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2025
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
08/20/2025 and conducted by Evaluator Tena Herrera
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250820121118

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:
08/23/2025
UNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:Iren Creighton - AdministratorTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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2
3
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9
Staff are denying a resident from making phone calls.
Staff are mishandling a resident's medications
INVESTIGATION FINDINGS:
1
2
3
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5
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7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to investigate the above allegations. LPA met with Administrator Iren Creighton and explained the purpose of today's visit.

The investigation consisted of the following:

On 8/21/2025 LPA reviewed Medications and Medication Administration Record for 5 residents, Reviewed 5 Resident Files, interviewed 3 staff and 4 residents, LPA attempted to interview 2 additional residents, however, due to cognitive disabilities the interviews were not successful. LPA interviewed responsible party for Resident #1 prior to leaving facility.
During todays visit 8/23/2025 LPA delivered findings on the above allegations.

(continued on the LIC9099-C page)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20250820121118
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CHLOIE'S COTTAGE
FACILITY NUMBER: 197607071
VISIT DATE: 08/23/2025
NARRATIVE
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The investigation revealed the following:
Allegation: Staff are denying a resident from making phone calls.
It is alleged that staff do not allow R1 to use the facility phone. LPA interviewed 4 residents and 3 out of 4 residents denied the above allegation and stated although they have not needed to make any phone calls they do not believe staff will restrict them of making any calls. LPA observed location of phone to be within the locked staff office that also holds all secured resident and staff files. During interviews with Staff, S2 stated that recently the phone has been relocated from the kitchen to the staff office as R1 has made unnecessary 911 calls. Interviews with 5 staff, each denied the above allegation and stated that residents are allowed to use the facility phone, however, when R1 asks to use the phone, they ask who R1 will be calling and often times staff will dial the number for R1 and give privacy for the phone call, staff added that this is done due to R1 making unnecessary 911 calls. S1 and S3 also confirmed S2’s statements. LPA reviewed R1s file and did not observe any notes of R1 making false/non-emergency 911 calls, there was no change of condition due to this being a continuous issue, there has been no reappraisal done for resident on how staff will assist resident with these new alleged behaviors and LPA reviewed Special Incident Reports (SIR’s) that have been sent to the department and there were no SIR’s received for these alleged 911 calls. LPA asked administrator for any notes on these alleged 911 calls and Administrator could not provide that information. Allegation is Substantiated.
Allegation: Staff are mishandling a resident's medications.
It is alleged that staff are not providing R1 with their prescribed medicine. LPA interviewed 5 staff and 5 out of 5 staff denied the above allegation and stated that residents are provided with medications that are prescribed by their physician and given per the doctors orders. LPA interviewed 4 residents and 3 out of 4 residents denied the above allegation and stated they are provided with their prescribed medications. LPA conducted a medication review and LPA observed R1’s medications to have dates that were not with complete medications (medications are prepackaged by day/time), when LPA asked staff why the dates were not matching, S2 and S3 stated that they recently took over medication administration and the medications were like that when they started and they have been pulling the correct medication but from future dates to ensure resident is still being administered the correct medication. During medication review LPA also noticed R1 to have a medication that is not listed within the doctors medication list nor the residents physician report, LPA also noticed that R5 was missing 1 routine medication and 1 PRN from their prescribed medications these medications were listed on R5’s current physician report dated 5/6/2025. Allegation is Substantiated. (Continued on LIC9099-C page)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20250820121118
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CHLOIE'S COTTAGE
FACILITY NUMBER: 197607071
VISIT DATE: 08/23/2025
NARRATIVE
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Additionally, during medication review LPA noticed that the Medication Administration Record (MAR) was not being signed for after administering medication to residents when LPA questioned staff, S3 stated that the medications have been administered they just sometimes forget to sign the MAR. Signatures were missing for 4 out of 14 medications for R1. This will be cited on a separate case management visit.


Based on LPAs observations, interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview held, and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 28-AS-20250820121118
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 08/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/24/2025
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidence by:
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Licensee/Administrator to obtain current medication lists for each resident and must have all medications that are listed in their prescribed medication boxes and submit photos of proof to LPA via email by POC due date. tena.herrera@dss.ca.gov
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During medication review LPA observed 1 medication within R1's prescribed medications to not have a doctors order documented for it, additionally R5 was missing 1 routine medication and 1 PRN from their prescribed medications these medications were listed on R5’s current physician report dated 5/6/2025.
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Type B
09/01/2025
Section Cited
CCR
87468.1(a)(14)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (14) To have reasonable access to telephones, to both make and receive confidential calls. The licensee may require reimbursement for long distance calls. This requirement was not met as evidence by:
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Licensee/Administrator to make phone accessible to all residnets and a training on all residnet personal rights must be conducted with all staff that include the right to make and receive confidential phone calls. The training must be completed by POC due date and a copy of the training materials and participant sigatures must be emailed to LPA by POC due date.
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LPA observed facility phone to not be reasonably accessible to residents as it has been moved from the kitchen to the locked staff office. R1s calls are being monitored, per staff R1 allegedly calls 911 for non emergency matters but there was no documentaion or poof porvided to LPA of these alleged calls and continuous behaviors.
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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: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20250820121118
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CHLOIE'S COTTAGE
FACILITY NUMBER: 197607071
VISIT DATE: 08/23/2025
NARRATIVE
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The investigation revealed the following:

Allegation: Staff are locking and isolating a resident inside of the facility.
It is alleged that staff put R1 in a different room, isolated them and locked the door. Interview with R1 revealed that they are ambulatory, however, there have been times a chair has been left at the entrance of their room making it difficult to exit their room but the door has never been locked and they have never been confined in their room. LPA interviewed a total of 4 residents and 3 out of 4 residents denied the allegation and stated they have never been locked or isolated by staff at the facility. LPA interviewed 5 staff and 5 out of 5 staff denied the above allegation and stated they do not lock or isolate residents in their room and that R1 is ambulatory which allows them to ambulate freely throughout the facility. LPA interviewed 4 residents and 4 out of 4 residents denied the above allegation and stated that they are not locked or isolated in their rooms, when LPA questioned staff about placing a chair in front of R1’s room each staff denied doing that or witnessing other staff do that. Allegation is unsubstantiated.

Allegation: Staff are not allowing a resident to file complaints.
It is alleged that the facility staff does not allow residents to file complaints to the Department. LPA observed the complaint poster at entrance hallway along with ombudsman poster and residents rights signage, that is displayed clearly and in an area all residents access. LPA interviewed 5 staff and 5 out of 5 staff denied the above allegation and stated that the residents are free to file complaints and make phone calls to do so. LPA interviewed 4 residents and 3 out of 4 residents denied the above allegation and stated they have never needed to file a complaint and don’t think they would be prevented of doing so. Allegation is unsubstantiated

Based on statements and interviews conducted with staff/residents, and LPA observations, there was not enough supportive evidence to concur with the reported allegations. 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 allegations are UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6