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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600990
Report Date: 08/09/2022
Date Signed: 08/09/2022 04:57:11 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/02/2022 and conducted by Evaluator Jey Cardenas
COMPLAINT CONTROL NUMBER: 11-AS-20220802152700
FACILITY NAME:COUNTRY COTTAGE 1FACILITY NUMBER:
198600990
ADMINISTRATOR:POST, KIMFACILITY TYPE:
735
ADDRESS:14508 FONTHILL AVETELEPHONE:
(310) 973-7416
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY:4CENSUS: DATE:
08/09/2022
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:TIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff do not adhere clients needs and services plan
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jey Cardenas conducted an unannounced initial 10 day complaint visit to the above facility to initiate complaint investigation in to the allegation: Staff do not adhere to clients’ needs and services plan. Upon arrival at the facility LPA met with house manager staff F.D and conducted a Covid-19 risk assessment, based on the assessment, the facility is clear of Covid-19 infection. LPA was later met by Licensee, Brenda Chandler and administrator, K.P; the purpose of the visit was explained.

Investigation consisted of: Initial complaint visit was conducted on 8/09/22, LPA Cardenas interviewed Westside Regional Center service coordinator, administrator, Licensee, and care staff, attempted to interview four (4) clients, and conducted client file record review. LPA obtained documentation pertinent to the allegation and copy of client/ staff roaster. LPA Toured physical plant.

Regarding allegation: Staff do not adhere clients’ needs and services plan.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
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 3
Control Number 11-AS-20220802152700
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: COUNTRY COTTAGE 1
FACILITY NUMBER: 198600990
VISIT DATE: 08/09/2022
NARRATIVE
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 It is being alleged that staff was observed transferring C1 without a gait belt. During the investigation LPA obtained digital evidence of the reported incidents. LPA reviewed the evidence and observed one (1) staff assisting C1 with transferring; C1 didn’t have gait belt on.

On 8/9/2022 LPA conducted client file review: Per Individual Service Plan review dated: 3/10/2022: Diagnoses: Mild intellectual disability, cerebral palsy, epilepsy, traumatic Brain injury secondary to auto to auto motor vehicle accident. Administrative team has been working diligently with medical doctor and health insurance to get authorization for continue therapy. Walker provides support with walking. “C1 should have on a gait belt for staff to support while another staff walk behind in case C1 needs to sit down.” Per Individual program plan (IPP) dated 1/06/2020 C1 has a goal to walk 15 to 20 feet to and from the bathroom with two person assist and a gait belt as gait is unsteady. Risk assessment: Are there any identifiable risks present? Yes; C1 ambulates with an unsteady gait and experiences seizures at times making more prone to falls. Risk is noted as: Falls Intervention: gait belt, staff assist. Per Physical therapy daily notes dated: 2/08/2022 Current complaints/ impaired standing, gait difficulty, risk for fall. C1 suffered traumatic brain injury and showed weakness….impaired standing, difficulty with functional mobility and gait difficulty. Patient Problems: Moderate assistance with mobility and transfers, moderate assistance of two person with gait training.

Per interviews with clients, LPA was unable to obtain clear accurate statement due to intellectual disability. Per interviews with Licensee, Administrator, and staff it was communicated to LPA that C1 utilizes gait belt for support, staff are trained in safety utilizing gait belts and C1s needs and service plans are followed.

Based on LPA’s observations, interviews, and record review(s), the preponderance of evidence standard has been met. On 8/9/22 LPA reviewed C1 service plan and it is documented that C1 should have on gait belt for staff to support. LPA obtained digital evidence that staff were not utilizing gait belt while assisting client with transfers. Therefore, the allegation, is found to be SUBSTANTIATED. California Code of Regulations, Title 22 are being cited on the attached LIC9099-D.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20220802152700
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: COUNTRY COTTAGE 1
FACILITY NUMBER: 198600990
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2022
Section Cited
CCR
80072(a)
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Personal rights To be accorded safe, healthful and comfortable accommodations... This requirement not met as evidenced by: During record review, C1 requires gait belt for support, LPA observed staff transferring C1 without gait belt. This poses a potential
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Licensee will ensure clients needs and services plans are followed. Gait belts shall be used by facility staff. Licensee will conduct a staff training and provide documentation of staff training regarding needs and services plans training plan to be sent to LPA.
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personal rights risk.
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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 M Alvarez
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3