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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600986
Report Date: 08/24/2021
Date Signed: 08/24/2021 04:02:40 PM

Unsubstantiated


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
07/14/2021 and conducted by Evaluator Rosaura Valenzuela
COMPLAINT CONTROL NUMBER: 31-AS-20210714154618
FACILITY NAME:CLAYTON COTTAGE GLENROSEFACILITY NUMBER:
198600986
ADMINISTRATOR:CLAYTON, CARYN M.FACILITY TYPE:
735
ADDRESS:3184 NORTH GLENROSE AVETELEPHONE:
(626) 797-7993
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY:6CENSUS: 6DATE:
08/24/2021
UNANNOUNCEDTIME BEGAN:
02:43 PM
MET WITH:Anne Arendtsz, StaffTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff physically abuses resident

Resident sustained bruises while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced subsequent complaint visit to obtain additional information and to deliver the findings for the above noted allegations. LPA met with Anne Arendstz, staff. The purpose of the visit was discussed.

It was alleged that facility Staff #1 (S1) is hitting Client #1 (C1 ) when C1 does not obey S1. It was also alleged that C1's body was covered with bruises. During the investigation on 07/16/21 at 11:30am and on 08/03/2021 at 3:00pm, LPA spoke with the facility staff, including S1. Interviews revealed that Client #1 (C1) likes to crawl under tables and on the floor and tends to bump into things, causing bruises on their body. S1 indicated that they do not work directly with C1 and have never mistreated or hit C1 or any other client.

On 08/03/21 at 2:45pm, LPA attempted to interview C1 and they were not able to answer any questions. Furthermore, with the staff assistance, C1's shirt and pants were lifted up and LPA did not observe any bruises
See 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
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 2
Control Number 31-AS-20210714154618
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: CLAYTON COTTAGE GLENROSE
FACILITY NUMBER: 198600986
VISIT DATE: 08/24/2021
NARRATIVE
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on the upper body or on the lower extremities.

Based on interviews and observation, there is not sufficient information to support the allegations. Therefore, the allegations are UNSUBSTANTIATED at this time.

Exit interview was conducted and a copy of the report was issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2