198600990-9-8-2022-11-AS-EMAZ-CK6V7D-20221013161057

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600990
Report Date: 09/08/2022
Date Signed: 09/08/2022 02:45:32 PM

Unsubstantiated

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
09/01/2022 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220901160609

FACILITY NAME:	COUNTRY COTTAGE 1		FACILITY NUMBER:	198600990
ADMINISTRATOR:	POST, KIM		FACILITY TYPE:	735
ADDRESS:	14508 FONTHILL AVE		TELEPHONE:	(310) 973-7416
CITY:	HAWTHORNE	STATE: CA	ZIP CODE:	90250
CAPACITY:	4	CENSUS: 3	DATE:	09/08/2022
		UNANNOUNCED	TIME BEGAN:	09:32 AM
MET WITH:	Kim Post		TIME COMPLETED:	03:01 PM

ALLEGATION(S):

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Staff prevents resident from praying before bed.

INVESTIGATION FINDINGS:

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On 09/08/22 Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent an unannounced complaint visit at this facility. LPA Dabuet was greeted by caregiver Fetima Dinsomore. Dinsmore contacted licensee and administrator Kim Post by telephone. LPA Dabuet met with the administrator and explained the purpose of today's visit.

The investigation included the following; A review of the Client roster, Staff roster, Face sheets, ID/Emergency, Individual Personal Plan, Medication Administration Records, and other pertinent documents associated with client #1 (C1). Interviews were conducted with clients #1- #4 (C2-C4) and staff #1 - #5 (S1-S5). A tour of the facility was conducted.

Evaluation Report continues on LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

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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Control Number 11-AS-20220901160609

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: 09/08/2022

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Staff prevents resident from praying before bed.

The details of the complaint alleged client #1 (C1) is denied his personal rights in expressing his prayers before bed. The complainant reports a staff prevented (C1) on 08/31/22 from saying his prayers.

An interview with administrator staff #1 (S1) that (C1) is accommodated services not included with the basic services on the admissions agreement. (C1) is a consumer of Westside Regional Center and is accommodated with a one on one care. (S1-S5) all claim they are made aware by the licensee that (C1) must have his daily prayers prior to bedtime. An interview with staff #2 (S2) observed (C1) voiced his prayers while in bed on 08/31/22. (S2) worked the evenings shift of 4pm-12am and claims she observed (C1) between 8pm -8:30pm say his prayers while he was in bed in his room. Interview with (S3) who worked on 08/31/22 during 4pm- 12pm collaborated (S2’s) claim and observed (C1) expressed his prayers that evening. (S3) reports that (C1) would have daily evening prayers with family members and cannot recall when (C1) ever missed this opportunity at night.

(C1) no longer resides at this facility effective 09/07/22 was interviewed by the Department by telephone. (C1) claims he was never denied of his personal rights and that he is able to say his prayers daily including 08/31/22. (C1) can not remember a time he missed his prayers. The Department attempted to interview clients #2-#4 (C2-C4) who were present at the facility and were unable to hold a conversation as a result of their disability. Interview with licensee staff #5 (S5) reports there is no written agreement which specified (C1) must have daily prayers must be conducted by the facility and that family representatives signed off in an agreement. However, (S5) states such request was honored by the facility base on verbal understanding a part of special personal accommodation for (C1) solely. (S5) asserts she is to be made aware if this accommodation is not performed. (S5) claims she did not receive any forms of communication for 08/31/22 regarding this matter. The facility provided a telephone log sheet for (C1) from 11/21/21 through 09/05/22 where it lists all the daily activities for (C1) including evening prayers were being conducted.

Evaluation Report continues on LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220901160609

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: 09/08/2022

NARRATIVE

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Based on information gathered, an inspection of the facility, observation, analysis of (C1)'s service records, and interviews conducted, the Department found no evidence to support the allegation mentioned in this complaint.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation are Unsubstantiated.

No deficiencies were cited during this visit.

An exit interview was conducted with Kim Post, and a copy of the report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

LIC9099 (FAS) - (06/04)

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