197608221-3-27-2023-28-AS-RORN-CRNQ6T-20230509115403

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608221
Report Date: 03/27/2023
Date Signed: 03/27/2023 04:15:13 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
03/21/2023 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230321165448

FACILITY NAME:	CHLOIE'S COTTAGE II		FACILITY NUMBER:	197608221
ADMINISTRATOR:	LINDA RENARD		FACILITY TYPE:	740
ADDRESS:	305 E. BASELINE ROAD		TELEPHONE:	(909) 592-4488
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	6	CENSUS: 6	DATE:	03/27/2023
		UNANNOUNCED	TIME BEGAN:	12:59 PM
MET WITH:	Linda Renard - Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff does not rotate and reposition resident causing resident to sustain pressure injuries.
Staff handles resident’s in a rough manner.
Staff left resident in soiled clothing for an extended period of time.
Staff not maintaining residents hygiene.
Staff refuses to provide resident a snack.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced initial complaint visit to determine the validity of the above-mentioned allegations. LPA met with Linda Renard (Administrator) and explained the reason for the visit.

The investigation consisted of the following: LPA obtained copies of the resident and staff rosters, interviewed Administrator, Staff 1 - Staff 3 (S1 - S3), Resident 1 - Resident 5 (R1 - R5) and hospice nurse. LPA reviewed R1's physician report, shower schedule and food supply.

The investigation revealed the following: regarding the allegation "staff does not rotate and reposition resident causing resident to sustain pressure injuries”, it is alleged that R1 sustained pressure sores on the back and bottom due to not being repositioned as often as needed. It is also alleged that R1 has a wound on the right shoulder and left knee. Administrator and staff denied the allegation and stated that R1 only has a scratch on the right shoulder that hospice is currently taking care. (Continued to LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230321165448

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 II	FACILITY NUMBER: 197608221
	VISIT DATE: 03/27/2023

NARRATIVE

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Interview with R1 revealed that R1 does not have any pressured injuries on the back or bottom. R1 confirmed the scratch on the right shoulder and it was due to self-harm. Interview with hospice nurse revealed that the last time they came to bathe the resident was on 03/24/2023 and no pressured injuries were observed on R1's back or bottom. Hospice is aware of the right shoulder scratch and has prescribed ointment and mittens. The scratch is healing properly. Facility staff has not been instructed by hospice to reposition R1. Also, R1 stated that for the most part R1 is able to move around and just requires some assistance or supervision. R1's physician report states that R1 is non-ambulatory and requires supervision, and may use a walker or wheelchair.

Regarding the allegation "staff handles resident’s in a rough manner", it is alleged that S1 handles R4 in an aggressive manner. Administrator and staff interviewed denied the allegation. Residents interviewed could not corroborate the allegation. During the visit, LPA observed staff handling the residents with care.

Regarding the allegation "staff left resident in soiled clothing for an extended period of time", it is alleged that all residents are left in soiled diapers all day and S1 does not change residents. Administrator and staff interviewed denied the allegation and stated they check the residents every 2 hours and change them as needed. Residents interviewed could not corroborate the allegation.

Regarding the allegation "staff not maintaining residents hygiene", it is alleged that residents are bathe twice a week, but there are times that residents “smell” and no baths are given because they were already bathe the day before. Administrator and staff interviewed denied the allegation. They stated that residents are bathe twice a week (each resident has different dates), but they receive bed bath everyday in the morning and before bed time. Residents interviewed could not corroborate the allegation and confirmed the staff statement.

Regarding the allegation "staff refuses to provide resident a snack", it is alleged that S1 refuses to give R3 snacks. Administrator and staff interviewed denied the allegation and stated that the residents receive 3 meals a day and at least 2 snacks a day. Interviewed with R3 revealed that staff have not denied giving R3 a snack.

Although the allegations may have happened or is 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 the report was provided

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

LIC9099 (FAS) - (06/04)

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