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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600990
Report Date: 08/17/2022
Date Signed: 08/17/2022 12:35:47 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, 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
08/10/2022 and conducted by Evaluator Jeremiah Randle
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220810111658
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: 4DATE:
08/17/2022
UNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH:Fetima Dinsmore House Mgr TIME COMPLETED:
01:02 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is interfering with resident's ability to have visitors.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 8/17/2022 at 9:30a.m. Licensing Program Analyst (LPA) Jeremiah Randle conducted an unannounced visit to deliver the findigs of the complaint with the above allegation. LPA identified himself and discussed the purpose of the visit and the elements of the allegation with Administrator Kim Post.
LPA conducted interviews of staff member (S1)-(S7) and reviewed documents from the facility.
It was alleged that facility is not allowing visitation. Reporting party called CCL to report that resident (R1) was not being allowed visitors. LPA conducted 10-day complaint inspection on 8/17/22 and conducted confidential interviews with staff, resident (R1) and Complaintant . Based on records review and confidential interviews. However, during records review LPA was provided a copy of Covid Visitor Log where Complaintaint had signed in on the date in question.
Based on LPA’s observations and interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegation is found to be unsubstantiated.
Exit interview was conducted with the Administrator Kim Post and a copy of this report was provided.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jeremiah Randle
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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