198600990-9-13-2022-11-AS-MVAO-CMCV44-20221222150544

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600990
Report Date: 09/13/2022
Date Signed: 09/13/2022 02:27:42 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
09/06/2022 and conducted by Evaluator Antonia Alvizar

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220906151922

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:	09/13/2022
		UNANNOUNCED	TIME BEGAN:	08:05 AM
MET WITH:	Kim Post, Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility staff did not assist resident with hygiene

INVESTIGATION FINDINGS:

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On 09/13/22 Licensing Program Analyst (LPA) Antonia Alvizar conducted an unannounced complaint visit at this facility. LPA Alvizar met with Administrator, Kim Post and explained the purpose of today's visit.

The investigation included the following; A review of the Client roster, Staff roster, Individual Personal Plan, facility plan, and other pertinent documents associated with client #1 (C1). Interviews were conducted with clients #1- #4 (C2-C4), staff #1 - #5 (S1-S5) and witness #1(W1). A tour of the facility was conducted.

Evaluation Report continues on LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonia Alvizar
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022

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-20220906151922

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: COUNTRY COTTAGE 1	FACILITY NUMBER: 198600990
	VISIT DATE: 09/13/2022

NARRATIVE

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Evaluation Report continues on LIC 9099C

Regarding the allegation: ““Facility staff did not assist resident with hygiene.” On 09/13/22 LPA Alvizar attempt to interview C2-C4 at the facility for complaint but due to clients’ disabilities C2-C4 were not able to answer questions regarding the allegation, client C1 was interviewed via phone, C1 repeated the questions LPA Alvizar asked. 5 out of 5 staff interviewed disagreed with the allegation staff S1 stated “They get haircuts when we see their hair is grow out, shaving is done as needed because everyone hair grows different”. Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated." LPA Alvizar reviewed clients reports and observe that Clients received a haircut in the months of September and July of 2022.

No deficiencies cited. An exit interview was conducted, and a copy of this report was provided to Administrator, Kim Post.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonia Alvizar
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022

LIC9099 (FAS) - (06/04)

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