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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609011
Report Date: 05/03/2023
Date Signed: 05/03/2023 03:12:57 PM


Document Has Been Signed on 05/03/2023 03:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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



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
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Ricky DesahagunTIME COMPLETED:
03:20 PM
NARRATIVE
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On 05/03/2023 in conjunction with a subsequent complaint visit control number 31-AS-20230427111039, Licensing Program Analyst (LPA) Rios did an unannounced CASE MANAGEMENT - Deficiencies visit. LPA met with Administrator Designee Ricky Desahagun, LPA spoke with Administrator David Taylor over the phone informed them of the purpose of the visit.

On 05/02/2023 during interviews with staff and residents it was revealed resident #3 (R3) had a fall some time in the week of 04/09/2023. Interview with Ricky on 05/03/2023 revealed a nurse from Home Heath had seen R3 who took her vitals and reported no issues. A physical therapist had also visited the resident but informed facility R3 could not continue because resident was complaining of pain when moved. According to Ricky, physical therapy was placed on hold until R3 is examined to determine they are fine to continue with physical therapy. LPA advised Ricky resident needs to receive medical attention to rule out serious injury from fall. Ricky called the Administrator David who informed Ricky, R3 is in hospice. Ricky could not provide to LPA name of hospice or date of admission to hospice for R3. On 05/03/2023 LPA made a follow-up visit to confirm if resident had received medical attention. Administrator David informed LPA R3 was seen by Home Health and is being placed on hospice. Administrator David could not provide name of Hospice or date of admission to hospice. LPA again advised Ricky and David to call 911. Ricky called 911 at 10:55 a.m. and ambulance arrived at 11:38 a.m. to transport R3 to the hospital.

On 05/02/2023 LPA observed Ricky count medication and LPA compared the count with Centrality Stored Medication Logs and Medication Administration Records (MAR). LPA observed pill counts were over the total quantity number of pills listed on the prescribed medication bottles for resident #2(R2) and resident #6(R6). LPA spoke with the Administrator David over the phone and Administrator explained, “They shouldn’t do that, I’ve trained them.” In reference to staff pouring pills from one bottle to another.
(LIC809-C Continued)
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
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.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 05/03/2023 03:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

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(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis...This requirement is not met as evidenced by:
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Licensee will provide to LPA copy of written instructions left to staff: that they are not to wait to call 911 when they witness or suspect an injury to residents in care. Licensee shall also make an addendum to their Program to include instructions above and provide a copy to CCL to be added to facility file
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Based on document review and interviews the Licensee did not call 911 for R3 when they were notified R3 had a fall in the facility and R3's health condition changed. This poses a potential health and safety or personal rights risk to residents in care.
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by POC due date.
Type B
05/05/2023
Section Cited

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(h)The following requirements shall apply to medications which are centrally stored:(5)Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
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Licensee will identify medication that is over quantity and ascertain from pharmacy what was the expiration date for the previous medication. Staff will complete LIC 622 for all future medication for all residents. Licensee will email completed LIC 622 for all residents in care by POC due date.
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Based on observation and interviews the Licensee did not ensure prescribed medication was kept in their original containers for two out of six residents. 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.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
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
LIC809 (FAS) - (06/04)
Page: 2 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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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(Continued Lic809-C)
Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiency was observed and cited (Refer to LIC 809-D).

Copy of this report provided, appeal form given. Exit interview conducted.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
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
LIC809 (FAS) - (06/04)
Page: 3 of 3