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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609011
Report Date: 05/03/2023
Date Signed: 05/03/2023 02:59:34 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
04/27/2023 and conducted by Evaluator Evelin Rios
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20230427111039
FACILITY NAME:STRAWBERRY COTTAGEFACILITY NUMBER:
197609011
ADMINISTRATOR:TAYLOR, DAVID JAMESFACILITY TYPE:
740
ADDRESS:43732 SENTRY LANETELEPHONE:
(661) 266-7995
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 6DATE:
05/03/2023
UNANNOUNCEDTIME BEGAN:
10:06 AM
MET WITH:Ricky DesahagunTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Licensee does not dispense medication as prescribed to resident(s) in care.
Licensee does not assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
Staff do not safeguard resident's personal property.
Resident's mattress is in disrepair.
INVESTIGATION FINDINGS:
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On 05/03/2023 Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced subsequent complaint visit for the above allegations. LPA arrived at the facility at 10:00 a.m. and was greeted by staff #1 (S1) who granted access. Ricky Desahagun called the facility as LPA was checking in and LPA informed Ricky about the purpose of the visit. Ricky met LPA shortly after.

At 10:21 a.m. LPA conducted a follow-up interview with one out of six residents. At 10:36 a.m. LPA reviewed and obtained further documents relevant to this investigation.

Allegation #1: Licensee does not dispense medication as prescribed to resident(s) in care.
It is alleged Licensee has withheld prescribed medication from R1. To investigate this allegation on 05/02/2023 LPA observed Ricky count medication and LPA compared the count with Centrality Stored Medication Logs and Medication Administration Records (MAR).
(Continued on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
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
Control Number 31-AS-20230427111039
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: STRAWBERRY COTTAGE
FACILITY NUMBER: 197609011
VISIT DATE: 05/03/2023
NARRATIVE
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(LIC9099-C Continued)
LPA observed two prescribed medications listed on Centrally Stored logs with Date Started 05/01/2023 for R1. On 05/02/2023 Ricky could not provide medications and revealed medications are not in the facility. Interview with Ricky on 05/02/2023 revealed the Centrally Stored Medication Log is created and provided by the pharmacy and medication was previously provided but has not been delivered by the pharmacy. Ricky could not explain why the Date Started is filled in with 05/01/2023 when the medication is not in the facility. On 05/03/2023 at 11:12 a.m. interview with Ricky revealed one medication for R1 was ordered on 05/01/2023 should be delivered in 2-3 days for R1. Based on observation and interviews, the allegation mentioned above is Substantiated at this time.

Allegation #2: Licensee does not assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
It is alleged Licensee did not arrange for follow-up appointments for R1. To investigate this allegation LPA reviewed facility's Program: Resident Handbook Of House Rules which indicates the facility is responsible for ALL doctor's and medical appointments, whether routine or in an emergency. During an Emergency Room (ER) visit on 04/20/2023 and 04/24/2023 R1 received instructions to have follow-up appointments with primary doctor. R1 notified Administrator David of instructions given by ER. A follow-up appointment was not determined to be made promptly. Subsequently it was determined an appointment was made after a third visit to the ER on 05/01/2023. Based on interviews and record review, the allegation mentioned above is Substantiated at this time.

Allegation #3: Staff do not safeguard resident's personal property.
It is alleged mail addressed to R1 had disappeared from where they were originally observed to be. On 05/02/2023 at 05:45 p.m. LPA observed a letter addressed to R1 peeking out from behind a propped-up staff calendar on the administrator’s desk. Interviews with two out of two staff revealed mail is gathered and placed on top of a small fridge located in the office to be handed out to residents. Staff could not explain why a letter would be behind a staff calendar. Based on observation and interviews, the allegation mentioned above is Substantiated at this time.

(Continued on LIC9099-C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 31-AS-20230427111039
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: STRAWBERRY COTTAGE
FACILITY NUMBER: 197609011
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/05/2023
Section Cited
CCR
87645(a)(4)
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(a) A plan for incidental medical and dental care shall be developed by each facility... by compliance with the following:(4)The licensee shall assist residents with self administered medications as needed.
This requirement is not met as evidenced by:
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Licensee shall submit receipt for medication not located in facility and a picture of medication taken at the facility. A copy of the receipt and medication shall be provided to CCL/LPA by POC due date.
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Based on document review and interviews the Licensee did not ensure R1 was administered medication as prescribed. This poses an immediate health and safety or personal rights risk to residents in care.
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Type B
06/08/2023
Section Cited
CCR
87468.1(a)(15)
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(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(15)To send and receive unopened correspondence in a prompt manner. This requirement is not met as evidenced by:
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Licensee shall submit a statement of understaning on cited regulation 87468.1(a)-(b) and provide a copy in writing of the process facility will use to promptly proved unopen mail to residents. A copy of statemen and process shall be provided to LPA by POC due date.
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Based on interviews and observation the Licensee did not ensure R1 received their correspondence in a prompt manner. This posed a potential health and safety or personal rights 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: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 31-AS-20230427111039
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: STRAWBERRY COTTAGE
FACILITY NUMBER: 197609011
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/08/2023
Section Cited
CCR
87307(a)(3)(A)
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(a) Living accommodations and grounds shall be related to the facility's function... The following provisions shall apply:(3) ...the licensee shall assure provision of:(A)A bed for each resident...appropriate sized bed. Each bed shall be equipped with good springs, a clean and comfortable mattress...This requirement is not met as evidenced by:
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Licensee has agreed to purchase new mattress for the residents that are not provided one by other means. Licensee will submit to LPA a receipt and picture of new mattress purchased for residents identified to need one to LPA by POC due date.
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Based on interviews and observation the Licensee did not ensure 4 out 6 residents had good spring, clean and comfortable mattresses. This poses a potential health and safety or personal rights 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: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 31-AS-20230427111039
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: STRAWBERRY COTTAGE
FACILITY NUMBER: 197609011
VISIT DATE: 05/03/2023
NARRATIVE
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(LIC9099-C Continued)
Allegation #4: Resident's mattress is in disrepair.
It is alleged a mattress for resident #3 (R3) is causing bruising on R3’s back. To investigate this allegation on 05/03/2023 LPA and Ricky conducted a physical plant tour of four out of four bedrooms and observed four out of six mattresses. LPA observed R6’s mattress to have a tear on the side of the mattress. LPA observed R3’s mattress to be discolored, have a brownish color stain, and have tears on the bottom side of the mattress. LPA observed Resident #4’s (R4) mattress to have tears on the top of the mattress. Based on observation and interviews, the allegation mentioned above is Substantiated at this time.

Deficiencies issued per CA Code of Regulations, Title 22 (refer to LIC9099-D). Report signed and delivered. Exit interview conducted.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6