197609011-4-14-2023-31-AS-NGID-CRQQ6L-20230511115342

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609011
Report Date: 04/14/2023
Date Signed: 04/14/2023 04:18:00 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/24/2020 and conducted by Evaluator Shira Stamps

COMPLAINT CONTROL NUMBER: 31-AS-20200624133943

FACILITY NAME:	STRAWBERRY COTTAGE		FACILITY NUMBER:	197609011
ADMINISTRATOR:	TAYLOR, DAVID JAMES		FACILITY TYPE:	740
ADDRESS:	43732 SENTRY LANE		TELEPHONE:	(661) 266-7995
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 6	DATE:	04/14/2023
		UNANNOUNCED	TIME BEGAN:	03:40 PM
MET WITH:	David Taylor		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident is being illegally evicted
Facility did not release resident's personal belongings

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Shira Stamps conducted an unannounced subsequent complaint visit for the above allegations. Entrance interview conducted with the Administrator. On 9/6/22, LPA collected documents and on 9/16/22 LPA conducted interviews and collection additional documents.

Allegation: Resident is being illegally evicted

It is alleged that the resident (R1) was rushed to the hospital, and the facility would not accept R1 back into the facility. Based on record review, it was found that R1 was discharged and notified on 6/12/20 that Hospice Care services could no longer meet the needs of R1, and it was recommended by Hospice that R1 go to a different type of facility such as a pain clinic due to R1’s increased demand for pain medications. It was noted that Hospice explained the plan to R1 and R1 verbalized understanding. On 6/16/20, an incident report was sent to Community Care Licensing (CCL) stating that R1 wanted to go to the hospital because of foot pain that was being treated by Hospice Care. CONTINUED...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

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 31-AS-20200624133943

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: STRAWBERRY COTTAGE	FACILITY NUMBER: 197609011
	VISIT DATE: 04/14/2023

NARRATIVE

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911 arrived and R1 was assessed and taken to the hospital. The incident report states later that evening the doctor called the Administrator and informed him that R1 does not belong in a Residential Care Facility for the Elderly (RCFE) home anymore, and it was suggested that she would benefit from a rehab program. Interviews indicated the social worker at the hospital would place R1 in a medical facility. LPA was unable to obtain documentation from the hospital stating R1 needs a higher level of care. On 6/14/20, the facility completed a reappraisal stating the resident should be returned to a higher level of care as recommended by Hospice and the Hospital. On 6/17/20, the Administrator informed R1’s representative party that R1 had been moved to a medical facility by the hospital due to the need of more care. Based on interviews it was indicated that the hospital recommended and placed R1 into a facility with a higher level of care. Interviews and documentation do not show that the facility refused to accept R1 back into the facility. Therefore, due to lack of supportive evidence the allegation, “Resident is being illegally evicted” is deemed unsubstantiated.

Allegation: Facility did not release resident's personal belongings

It is alleged that R1 was unable to get their belongings after being rushed to the hospital. Based on document review, the facility sent a letter on 6/26/20 to R1’s representative party requesting that they pick up R1’s personal belongings. Document review also found that R1’s representative party signed a statement confirming that all of R1’s personnel belongings were picked up on 6/29/20. Therefore, based on document review, the allegation, “Facility did not release resident’s personal belongings,” is deemed unsubstantiated.

Exit interview conducted. Copy of report delivered to Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC9099 (FAS) - (06/04)

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