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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609865
Report Date: 03/04/2022
Date Signed: 03/04/2022 02:07:17 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,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/09/2020 and conducted by Evaluator Tuesday Cabiness
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20200109083157
FACILITY NAME:COTTAGES OF LAKE BALBOA 1, THEFACILITY NUMBER:
197609865
ADMINISTRATOR:LEVI, JUSTINFACILITY TYPE:
740
ADDRESS:6724 GAVIOTA AVETELEPHONE:
(747) 264-1004
CITY:LAKE BALBOASTATE: CAZIP CODE:
91406
CAPACITY:6CENSUS: 6DATE:
03/04/2022
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Justin LeviTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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1. Use of Improper Restraints Resulting in Injury
2. Failure to provide adequate Observation of Resident's Condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tuesday Cabiness met with Administrator Justin Levi to deliver to final findings of the allegations mentioned above. This investigation was conducted by Investigator Jose Santana from Community Care Licensing Division’s (CCLD’s) Investigations Branch (IB). The following was determined:

Allegation # 1: Use of Improper Restraints Resulted in injury to Resident: On January 09, 2020, the Woodland Hills Regional Office (RO) received a complaint regarding an allegation of the use of improper restraints resulted in Resident #1 (R1) sustaining multiple bruises and head injury. On January 13, 2020, former LPA A. Arambulo conducted the initial visit, and obtained facility and resident documents. On February 04, 2020 and February 07, 2020 IB Investigator Santana visited the facility and obtained further documents pertaining to the complaint. Interviews were also conducted by IB Investigator Santana with the resident/victim, family
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
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 8
Control Number 31-AS-20200109083157
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: COTTAGES OF LAKE BALBOA 1, THE
FACILITY NUMBER: 197609865
VISIT DATE: 03/04/2022
NARRATIVE
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of resident, staff, other residents and Administrators on January 18, 2020; January 21, 2020; January 24, 2020; January 30, 2020; and February 04, 2020.

Based on interviews, R1 was admitted to the facility on August 08, 2018, with several physical and mental disabilities and labeled as a “high fall risk”. Based on a physician’s report dated September 10, 2019, R1 was non-ambulatory and should not ambulate, transfer, or toilet without assistance; and needed assistance with activities of daily living (ADL’s). Incident reports and facility documents revealed that R1 had prior unwitnessed falls. As a result of the falls, the facility installed full bed rails to secure R1 in the bed (although R1 was not on hospice). On January 15, 2019 and December 28, 2019, R1 continued to have falls, as well as behavioral issues in the night in which R1 sustained injuries and staff had difficulty keeping R1 in the bed.

On January 15, 2019, it was documented that R1 was agitated and attempted to get out of bed and was assisted by staff. Somehow an unwitnessed fall occurred and R1 got out of bed alone, fell backward, and hit R1’s head on the wall. R1 sustained “several bumps.” On December 28, 2019, at 4:50am, R1 attempted to get out of bed and climbed over the bed rails. It was reported during the investigation by IB Investigator Santana that R1 had two unwitnessed falls in which R1 sustained multiple bruises, a skin tear, and forehead contusion. The improper use of bed rails caused the impact of the fall to be more severe. Further, staff left R1 unattended even though R1 was at risk of attempting to get out of bed. R1’s history of attempting to get out of bed is evidenced by R1 being on anxiety medication to control R1’s behaviors, and staff installing a motion sensor in order to prevent resident from getting out of bed. The facility accepted and retained the resident, knowing R1 was a “high fall risk.” Due to the lack of care and supervision by staff, R1 sustained multiple bruises and a head injury. Also, during the incidents of the falls, facility staff failed to seek medical attention and notify R1’s responsible party in a timely manner. This is an immediate health and safety risk to residents in care. Therefore, there is evidence to corroborate the investigation conducted by IB, and the allegation “Use of Improper Restraints Resulting in Injury to Resident”, is Substantiated.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 31-AS-20200109083157
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: COTTAGES OF LAKE BALBOA 1, THE
FACILITY NUMBER: 197609865
VISIT DATE: 03/04/2022
NARRATIVE
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Allegation # 2: Failure to provide adequate Observation of Resident's Condition. On January 13, 2020, LPA A. Arambulo conducted the initial visit, and obtained facility and resident documents. On January 18, 2020, January 21, 2020, January 24, 2020, January 30, 2020, February 04, 2020, and February 07, 2020, from various times, interviews with resident/victim, family of resident, staff, witnesses, and Administrators were conducted, and documents pertaining to the complaint was obtained were reviewed.

Based on interviews, R1 was admitted to the facility on August 08, 2018, with several physical and mental disabilities and labeled as a “high fall risk”. Based on a physician’s report dated September 10, 2019, R1 was non-ambulatory and should not ambulate, transfer, or toilet without assistance; and needed assistance with activities of daily living (ADL’s). Incident reports and facility documents revealed that R1 had prior unwitnessed falls. As a result of the falls, the facility installed full bed rails to secure R1 in the bed (although R1 was not on hospice). On January 15, 2019 and December 28, 2019, R1 continued to have falls, as well as behavioral issues in the night in which R1 sustained injuries and staff had difficulty keeping R1 in the bed. It was also reported that on December 28, 2019, at 4:50am, R1 attempted to get out of bed and climbed over the bed rails. It was reported, that R1 had two unwitnessed falls in which R1 sustained multiple bruises, a skin tear, and forehead contusion. The improper use of bed rails caused the impact of the fall to be more severe. R1’s history of attempting to get out of bed is evidenced by R1 being on anxiety medication to control R1’s behaviors, and staff installing a motion sensor in order to prevent resident from getting out of bed. Through all the information obtained, interviews and documentation, the facility updated R1’s needs and service/appraisal plan on February 05, 2020, a year later, to address the issues and problems the facility was experiencing with R1. And because the facility accepted and retained R1, knowing R1 was a “high fall risk” and diagnosed with a mental health condition. This is an immediate health and safety risk to resident in care. There is sufficient evidence, the facility, This is an immediate health and safety risk to resident in care. There is sufficient evidence, the facility, “Failed to provide adequate observation of resident’s condition”, therefore the allegation is deemed SUBSTANTIATED.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 31-AS-20200109083157
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: COTTAGES OF LAKE BALBOA 1, THE
FACILITY NUMBER: 197609865
VISIT DATE: 03/04/2022
NARRATIVE
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A $500 immediate civil penalty is assessed today for a violation resulting in injury to R1. The licensee/administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).

Exit interview conducted. Appeal rights given. A copy of the report was issued.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 31-AS-20200109083157
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: COTTAGES OF LAKE BALBOA 1, THE
FACILITY NUMBER: 197609865
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
03/04/2022
Section Cited
CCR
87608
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Postural Supports: (a) Based on the individual's preadmission appraisal..for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports maybe...
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Administrator and LPA discussed during the visit, the plan of correction will be to continue to ensure that all residents who have bed rails, has proper documentation or a hospice care plan. Currently, there are (2)
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 used to achieve proper body position and balance...but not limited to, preventing a resident from falling out of bed..This requirement was not met, evidenced by, based on incident reports, the facility installed full bed rails to secure R1 in the bed (although R1 was not on hospice). and R1 sustained serious injuries. This is a potential health and safety risk to resident in care.
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residents who are on hospice with proper documentation for bed rails.
POC cleared during visit
Request Denied
Type B
03/04/2022
Section Cited
CCR
87466
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Observation of Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning...the licensee shall ensure that such changes are
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Administrator and LPA discussed during the visit, the plan of correction will be to continue to ensure that all residents have current re-appraisals and needs and service plan, as well as current physician reports.
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documented...This requirement was not met as evidenced by: during the investigation, the facility accepted and retained R1, when knowing R1 was a “high fall risk.” Because of the improper use of bed rails, the impact of the fall caused severe injuries to R1. This is a potential health and safety risk to residents in care.

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Currently all residents documents are current and updated. POC cleared during visit.
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: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/09/2020 and conducted by Evaluator Tuesday Cabiness
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20200109083157

FACILITY NAME:COTTAGES OF LAKE BALBOA 1, THEFACILITY NUMBER:
197609865
ADMINISTRATOR:LEVI, JUSTINFACILITY TYPE:
740
ADDRESS:6724 GAVIOTA AVETELEPHONE:
(747) 264-1004
CITY:LAKE BALBOASTATE: CAZIP CODE:
91406
CAPACITY:6CENSUS: 6DATE:
03/04/2022
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Justin LevyTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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1. Faciltiy failed to provide sufficient activities
2. Failure to provide meals of adequate Quality
3. Failure to provide sufficient staff
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tuesday Cabiness met with Administrator Justin Levi to deliver to final findings of the allegation mentioned above. The following was determined:

On January 09, 2020, the Woodland Hills Regional Office (RO) received a complaint regarding an allegation of the of the facility failed to provide adequate observation of resident’s condition resulted in Resident #1 (R1). On January 13, 2020, LPA Arambulo conducted the initial visit, and obtained facility and resident documents. On January 18, 2020, January 21, 2020, January 24, 2020, January 30, 2020, February 04, 2020, and February 07, 2020, from various times, interviews with resident/victim, family of resident, staff, witnesses, and Administrators were conducted, and documents pertaining to the complaint was obtained were reviewed.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 31-AS-20200109083157
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: COTTAGES OF LAKE BALBOA 1, THE
FACILITY NUMBER: 197609865
VISIT DATE: 03/04/2022
NARRATIVE
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Based on the information obtained, LPA determined that the facility provided musical activities monthly for the residents at the facility. LPA was able to observe videos of residents singing and dancing. And interviews revealed that staff assisted resident #1 (R1) to participate in the activities, but due to R1’s physical and mental disabilities, there were times R1 was not able to participate, based on R1’s tolerance. LPA was unable to interview any residents, due to the residents no longer living at the facility, at the time R1 was admitted. There is no evidence to support the allegation the facility failed to provide sufficient activities; therefore, the finding is UNSUBSTANTIATED at this time.

Allegation # 4: Failure to provide meals of adequate quality: Concerns were expressed, the facility failed to provide meals of adequate quality. On January 13, 2020, former LPA Arambulo conducted the initial visit, and obtained facility and resident documents. On January 18, 2020, January 21, 2020, January 24, 2020, January 30, 2020, February 04, 2020, and February 07, 2020, from various times, interviews with resident/victim, family of resident, staff, witnesses, and Administrators were conducted, and documents pertaining to the complaint was obtained were reviewed.

Based on the information obtained, it was revealed, resident #1 (R1)’s appetite was sporadic, and had difficulty eating, due to missing teeth. Staff was instructed to cut R1’s food into small pieces or puree. R1’s appetite fluctuated and would go days without eating and would spit out food. It was also reported that there were never any complaints or concerns expressed to the Administrator or staff in regard to the types of meals that were being provided to R1 or other residents. Based on interviews, there is an insufficient information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Allegation # 5: Failure to Provide Sufficient Staff: Concerns were expressed, the facility failed to provide sufficient staff. On January 13, 2020, former LPA A. Arambulo conducted the initial visit, and obtained facility and resident documents. On January 18, 2020, January 21, 2020, January 24, 2020, January 30, 2020, February 04, 2020, and February 07, 2020, from various times, interviews with resident/victim, family of resident, staff, witnesses, and Administrators were conducted, and documents pertaining to the complaint was obtained
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 31-AS-20200109083157
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: COTTAGES OF LAKE BALBOA 1, THE
FACILITY NUMBER: 197609865
VISIT DATE: 03/04/2022
NARRATIVE
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were reviewed. Information, and documentation obtained, including interviews, revealed there are (3) regular staff, including (2) Administrators that work in mornings. Administrator also reported to LPA that, they use other caregivers from other owned facilities (Cottages of Lake Balboa 2 and Cottage of Lake Balboa 3), which are adjacent to each other to cover staffing as needed. LPA observed the facility and requested the staff schedule and resident list. In the evening, there (2) PM staff, depending on the census. During the graveyard, it was reported that there could be at least (2) overnight staff that cover. Although, during the incidents with resident #1 (R1), who had (2) un-witnessed falls, it was revealed that there were (2) staff working the graveyard shift, which according to the census at the time R1 was residing, there was sufficient staff. Also, during facility visits during the investigation, LPA witnessed sufficient staff. Therefore, at this time, based on the information, observation, and interviews, the allegation is UNSUBSTANTIATED at this time.

Exit interview was conducted and a copy of the report was issued.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
LIC9099 (FAS) - (06/04)
Page: 8 of 8