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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609011
Report Date: 06/13/2023
Date Signed: 06/14/2023 02:44:44 PM

Substantiated


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
04/29/2022 and conducted by Evaluator Melissa Ruiz
COMPLAINT CONTROL NUMBER: 31-AS-20220429094057
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:
06/13/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:David TaylorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff failed to administer resident's medication as prescribed.
INVESTIGATION FINDINGS:
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At 10:00 a.m., Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility to conduct an unannounced subsequent complaint visit. LPA was greeted by staff and later met with Licensee, David Taylor. The purpose of the visit was explained, and an entrance interview was conducted. Allegation: Staff failed to administer resident's medication as prescribed. On 5/5/2022, LPAs Ruiz and Martinez conducted an initial visit. During this visit, LPAs conducted a random medication count for R1 from 11:30 a.m. – 12:00 p.m. and two medications Baclofen and Quetiapine Fumarate (Seroquel) were observed to be inconsistent with the medication instructions. The medication Baclofen was to be administered 3 times a day, and there were three separate bubble packs for morning, noon, and night. LPAs observed 2 pills in the a.m. packs for 5/5/22, and 5/3/22 and the Medication Administration and Record log (MAR) was signed by a staff member indicating that the medication was given on said dates. In addition, from 4/26 – 4/30, Quetiapine Fumarate (Seroquel), which was to be administered once at night, was administered using the May pack because some of the pills were missing for the month of April. Afterwards, the licensee contacted the pharmacy to replace the missing pills. MARs did not have a staff signature on 4/23, 4/24, and 4/25. Due to record review and LPA observation, the allegation above is substantiated. Deficiency issued per CCR, Title 22. Appeal rights issued. Report signed and delivered.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023
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 4
Control Number 31-AS-20220429094057
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
06/16/2023
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.

This requirement was not met as evidenced by:
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The licensee shall hire a State approved vendor to train all staff and licensee on medication assistance. Licensee shall submit proof of requesting/booking training by the POC due date and by 6/23/23, Licensee shall submit verification of training completed for all staff.
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Based on LPA observation and record review, two medications for R1 were not issued as prescribed and the MARs was not filled out correctly, due to staff not signing or signing in advance which poses an immediate health and safety risk to the 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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
04/29/2022 and conducted by Evaluator Melissa Ruiz
COMPLAINT CONTROL NUMBER: 31-AS-20220429094057

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: DATE:
06/13/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:David TaylorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff speaks inappropriate to resident.
Facility has not provided transportation to medical appointment.
Resident is being charged extra fees.
INVESTIGATION FINDINGS:
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At 10:00 a.m., Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility to conduct an unannounced subsequent complaint visit. LPA was greeted by staff and later met with the Administrator and Licensee, David Taylor. The purpose of the visit was explained, and an entrance interview was conducted.

Allegation: Staff speaks inappropriate to resident.

To investigate this allegation, LPA conducted interviews at 10:30 a.m. with two (2) staff, the Administrator/Licensee. On 5/5/22, LPA conducted interviews with 5 out of 5 residents who were able to communicate. On that same day, LPA interviewed two (2) staff and they stated that they have never witnessed any staff member speak inappropriately to any resident in care. The Administrator/Licensee stated that R1 was the one who engaged in disrespectful and rude name calling to staff, especially when making demands.

(cont. on LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20220429094057
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: 06/13/2023
NARRATIVE
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 All residents stated that they get along with staff and the staff have never spoken to them inappropriately. Due to interviews conducted, there is insufficient evidence to prove the allegation may or may not have occurred, therefore it is unsubstantiated at this time.

Allegation: Facility has not provided transportation to medical appointment.

It is alleged that the Licensee/staff did not provide transportation for R1. LPA interviewed the Licensee on 5/5/23, and he stated that they never refuse to transport any resident in care and do provide transportation to all residents for different outings, but specifically medical visits. The licensee also stated that they do not charge the residents for transportation, even though it is outlined in their Admission Agreement. The licensee stated that R1 had asked the staff to transport them to the lab to do a TB test, as a walk in however, it was insufficient notice to staff and/or licensee. Additionally, on 6/13/23, LPA reviewed R1’s admission agreement, which states that “All transportation arrangements require a minimum of 48-hours’ notice”.

Allegation: Resident is being charged extra fees.

On 5/5/22, an interview with R1 was conducted at 10:35 a.m. and R1 stated that the facility charges them around $4.00 for every Instacart delivery or service fee for using the application. On 5/5/22, an interview with the Licensee revealed that R1 does prefer to have their own personal groceries shopped and delivered with Instacart. The licensee also stated that Instacart uses R1’s EBT card for the groceries, however EBT does not cover tips, service fees, checkout bag fee, or beverage container fees. These additional fees are covered by the licensee’s own personal card, since the licensee places the orders for R1. In addition, on 6/13/23, LPA Ruiz reviewed various receipts for Instacart that reflect both EBT and Mastercard payment methods used for the groceries. The Mastercard charges range from $3.75, $5.32, $3.21, $4.22 and so forth. Due to interviews conducted and record review, the allegation above is deemed unsubstantiated.

No deficiencies issued. Report signed and delivered. Exit interview conducted.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4