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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609011
Report Date: 10/08/2025
Date Signed: 10/08/2025 04:33:40 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
02/21/2025 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20250221124252
FACILITY NAME:STRAWBERRY COTTAGEFACILITY NUMBER:
197609011
ADMINISTRATOR:GORY, MONICAFACILITY TYPE:
740
ADDRESS:43732 SENTRY LANETELEPHONE:
(661) 266-7995
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 3DATE:
10/08/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Monica Gory - AdministratorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff made inappropriate comments towards resident.
INVESTIGATION FINDINGS:
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On 10/08/2025 Licensing Program Analysts (LPA) Evelin Rios conducted an unannounced subsequent complaint visit for the above mentioned allegations. LPA arrived to the facility and was granted access by Staff #2 (S2). S2 contacted Monica Gory, the administrator by telephone and LPA explained the purpose of the visit. An entrance interview was conducted with the administrator. Administrator arrived at 3:50 p.m.

During the course of the investigation, LPA conducted an initial visit on 02/25/2025. During the initial visit, LPA interviewed the administrator and Staff #2 (S2). From approximately 10:54 a.m. to 1:26 p.m., LPA reviewed resident records and obtained copies, including but not limited to: Resident #1’s (R1’s) Resident Report and Observations, Unusual Incident/Injury Reports, Physician’s Report, and the facility’s Infection Control Plan. LPA also interviewed Resident #1 (R1), Resident #2 (R2) and attempted to interview Resident #5 (R5); however, Resident #5 (R5) did not respond to questions.
(Continue to LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025
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
WOODLAND HILLS S.RO, 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
02/21/2025 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20250221124252

FACILITY NAME:STRAWBERRY COTTAGEFACILITY NUMBER:
197609011
ADMINISTRATOR:GORY, MONICAFACILITY TYPE:
740
ADDRESS:43732 SENTRY LANETELEPHONE:
(661) 266-7995
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 3DATE:
10/08/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Monica Gory- Administrator TIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff inappropriately isolated resident.
Staff are not responding to resident's call button.
Staff are not providing adequate food service to resident.
INVESTIGATION FINDINGS:
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On 10/08/2025 Licensing Program Analysts (LPA) Evelin Rios conducted an unannounced subsequent complaint visit for the above mentioned allegations. LPA arrived to the facility and was granted access by Staff #2 (S2). S2 contacted Monica Gory, the administrator by telephone and LPA explained the purpose of the visit. An entrance interview was conducted with the administrator. Administrator arrived at 3:50 p.m.

During the course of the investigation, LPA conducted an initial visit on 02/25/2025. During the initial visit, LPA interviewed the administrator and Staff #2 (S2). From approximately 10:54 a.m. to 1:26 p.m., LPA reviewed resident records and obtained copies, including but not limited to: Resident #1’s (R1’s) Resident Report and Observations, Unusual Incident/Injury Reports, Physician’s Report, and the facility’s Infection Control Plan. LPA also interviewed Resident #1 (R1), Resident #2 (R2) and attempted to interview Resident #5 (R5); however, Resident #5 (R5) did not respond to questions.
(Continue to LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025
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 31-AS-20250221124252
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: STRAWBERRY COTTAGE
FACILITY NUMBER: 197609011
VISIT DATE: 10/08/2025
NARRATIVE
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On 09/09/2025, while conducting the unannounced annual required visit, at approximately 10:25 AM, LPA interviewed R4. During an unannounced subsequent complaint visit conducted on 09/29/2025, LPA interviewed Resident #3 (R3) and conducted telephone interviews with Staff #1 (S1) and Staff #3 (S3).
Allegation: Staff inappropriately isolated resident. Regarding the allegation is was reported that R1 has been isolated in their room for a month without an explanation. LPA's interview with R1 on 02/25/2025 indicated that they had been isolated for little over a week. R1 stated they only coughed once in a while and had a severe infection before that. R1 did not recall the date they were sick. Interview with the Administrator on 02/25/2025 confirmed R1 was isolated towards the end of January as a precaution because R1 had Covid-19 or flu-like symptoms such as constant cough with extreme phlegm. Administrator stated she contacted R1's responsible party to have R1 taken to the hospital to be examined and rule out covid-19 but they refused to take R1 and have R1 transported via ambulance. According to the Administrator they were following their infection control plan to minimize the spread of infection. LPA's interview with R2 on 02/25/2025 confirmed they had been sick with vomiting, cold, and pain recently and had been isolating in their room. According to R2 prior to getting sick they observed R1 was "very sick" and isolated for a week. Interview with three staff including the administrator corroborate R1 was exhibiting flu like symptoms and was isolated no more than a week. Interview with four (04) out (05) five residents with one (01) resident not responding to questions corroborate R1 had flu like symptoms coughing during mealtimes. LPA’s review of the facilities infection control plan verbatim “Facility will ensure separation and care of residents whose illness requires separation, including minimizing group and public activities and ensure residents are eating meals in their rooms.

Based on interviews conducted and record review there is insufficient evidence R1 was isolated for over a month therefore the allegation is deemed Unsubstantiated at this time.

Allegation: Staff are not responding to resident's call button. It is alleged that staff are not responding to Resident #1’s (R1’s) calls for assistance. On 02/25/2025, during LPA’s physical plant tour, LPA tested R1’s call button and observed it to be functional. In an interview conducted by LPA, R1 denied the allegation. R1 stated they had no issues with getting assistance but that staff had complained that R1 was pushing their call button all the time. R1 denied this stating they only push it when they need assistance. Interview with the Administrator and three (03) staff denied the allegation.
Page 2 of 3 (Continue to LIC9099-C)
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 31-AS-20250221124252
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: STRAWBERRY COTTAGE
FACILITY NUMBER: 197609011
VISIT DATE: 10/08/2025
NARRATIVE
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(Continued from LIC9099-C)According to S1 the button needed new batteries at some point (date unknown) but they would make their usual rounds anyway to check on residents. Interview with the Administrator revealed they had received complaints from staff alleging R1 was constantly pushing their call button after they had already provided assistance and the topic was discussed with R1. Interview with four (04) out four (04) residents interviewed deny the allegation stating they have no issues or concerns with getting assistance. Two (02) residents that also use the call button state they do not have any issue with response time once they push their button.

Based on interviews conducted and LPA's observation there is insufficient evidence staff are not responding to resident's call button, therefore the allegation is deemed Unsubstantiated at this time.

Allegation: Staff are not providing adequate food service to resident. It is alleged that R1 was not provided dinner on 01/20/2025. Additionally, when meals are served in R1’s bedroom, staff reportedly remove the food before R1 has finished eating and attempt to control what R1 eats. During LPA's interview with R1, R1 denied missing any meals or being prevented from finishing them. However, R1 did confirm that staff have attempted to regulate their sugar intake, limiting it to either three tablespoons or a sprinkle. Interview with R2 stated they had witnessed R1 pour sugar until it is all gone. Interview with the administrator and three staff corroborate R1 would pour what they believed was an excessive amount of sugar but would not deny R1 when they requested sugar because R1 does not have a physician's dietary restriction however they provided a smaller container of sugar for R1 to pour sugar from. Interview with three (03) out of four (04) residents interviewed deny a meal had not been provided or removed before they finished it and staff control what they eat.

Based on the interviews conducted, there is insufficient evidence to support the allegation that staff are not providing adequate food service to the resident. Therefore, the allegation is deemed Unsubstantiated at this time.




Exit interview conducted. Copy of report provided.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 31-AS-20250221124252
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: STRAWBERRY COTTAGE
FACILITY NUMBER: 197609011
VISIT DATE: 10/08/2025
NARRATIVE
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On 09/09/2025, while conducting the unannounced annual required visit, at approximately 10:25 AM, LPA interviewed R4. During an unannounced subsequent complaint visit conducted on 09/29/2025, LPA interviewed Resident #3 (R3) and conducted telephone interviews with Staff #1 (S1) and Staff #3 (S3). During todays visit LPA conducted follow-up interviews with three (03) out three (03) residents regarding this allegation.

Allegation: Staff made inappropriate comments towards resident. It is alleged that S1 made an inappropriate comment towards R1. LPA's interview with R1, confirmed the allegation stating, S1 told R1 if their family member came to the facility again, they would be arrested and it would be R1’s fault. R1 stated it was not the only time S1 spoke to them inappropriately and made them uncomfortable. LPA's interview with S1 denied the allegation stating R1's Family Member (FM) arrived to the facility when S1 was working and FM was aggressive and yelling. S1 warned them they would call the "cops because they did not feel safe". When S1 was on the phone with the police FM left the facility. S1 says the incident started with R1 and FM having an argument about a new phone. LPA's interview with two (02) out of four (04) residents interviewed corroborate the allegation that S1 has spoken to R1 inappropriately. One (01) out of four (04) residents denied witnessing S1 make inappropriate comments but that S1 had been rude without providing specific examples. LPA's interview with the administrator and two (02) other staff state they work different shifts and only see each other during shift changes. However the administrator and one (01) staff were not surprised by the allegation believing words may have been exchanged since FM was threatening staff. According to the administrator, there had been ongoing issues between R1 and FM. It was recommended to the administrator by Long Term Care Ombudsman (LTCO), and Libertana the Assisted Living Waiver (ALW) case worker to contact law enforcement if FM was threatening staff. Additionally, administrator was advised by LTCO to contact APS if they believed FM was verbally abusive towards R1. Even though FM was exhibiting aggressive behavior the administrator and two (2) staff confirmed that R1 had complained about S1’s treatment toward them.

Based on LPA's interviews with residents and staff there is sufficient evidence to support the allegation, staff made inappropriate comments to R1.

Deficiency cited (refer to LIC9099-D). Exit interview conducted. Appeal Rights provided. Copy of report provided.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 31-AS-20250221124252
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: STRAWBERRY COTTAGE
FACILITY NUMBER: 197609011
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2025
Section Cited
CCR
87468.1(a)(1)
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87468.1 (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by:
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The Administrator agreed to conduct an in-service training to all staff on the cited section and submit a proof of completion with staff submit sign-in sheet to LPA by the POC due date 10/31/2025.
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Based on LPA’s interviews, the licensee did not comply with the section cited above, as Staff #1 (S1) spoke inappropriately to Resident #1 (R1), posing a potential risk to the health, safety, or personal rights of individuals 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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6