198600990-9-21-2022-11-AS-MVAO-CMXS5L-20230110123431

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600990
Report Date: 09/19/2022
Date Signed: 09/21/2022 09:35:55 AM

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
09/12/2022 and conducted by Evaluator Pamela Bunker

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220912100349

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:	09/19/2022
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Kim Post		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility toilet support rail is in disrepair resulting in injury to resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Monday, September 19, 2022. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. LPA Bunker met with Administrator Kim Post. LPA Bunker explained the purpose of today's visit.

The investigation consisted of the following: LPA Bunker interviewed staff 1-4 (S1-S4). Client 1-3 (C1-C3) is non-verbal and unable to communicate. Administrator Ms. Post and LPA Bunker toured the facility for a health and safety check. Allegation #1: Facility toilet support rail is in disrepair resulting in injury to resident. S1-S4 stated the facility toilet rail is not broken. Client accidentally lightly scratched his left arm on the toilet safety rail getting up from the toilet. Staff assisted client the entire time and applied first aid. Client did not require hospitalization or any further medical treatment. The facility nurse Kate Muiron was on duty during the incident. LPA Bunker observed the toilet safety rail and it was operable and in good working condition. See continued LIC9099-C page 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022

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-20220912100349

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: 09/19/2022

NARRATIVE

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Continued LIC812-C page 2

Investigation revealed the following: Interviews were conducted with staff S1-S4 (S1-S4) who stated that the facility staff is trained, certified, and competent to provide the necessary care and supervision to meet the client's daily care needs. S1-S4 stated client 1 (C1) was moving his arms and put his left arm under the toilet safety rail, when C1 removed his arm C1's left arm was accidentally scraped by the toilet seat support bar. C1 sustained a light scratch on his left forearm. C1 has one on one assistance and staff was with C1 the entire time to assist. S1-S4 stated first aid was applied to C1's left arm. The facility nurse Kate Muiron, LVN was at the facility to provide assistance. C1 did not complain of any pain. S1-S4 stated that C1 did not require hospitalization or any further medical treatment. LPA Bunker observed the toilet safety rail and it was operable and in good working condition. The Licensee reported the Special Incident Report to all the appropriate agencies in a timely manner within Title 22 Regulation's required time frame. S1-S4 stated staff had no control over C1 quickly putting his left arm under the toilet safety rail and couldn't have prevented the incident from occurring it was an accident. S1-S4 stated the incident was reported prior to the complaint.

Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. 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 is deemed unsubstantiated.

A copy of the Complaint Investigation Report LIC9099, LIC9099-C, and Confidential Names LIC811 was provided to the facility Administrator Kim Post

There were no deficiencies cited.

An exit interview conducted.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022

LIC9099 (FAS) - (06/04)

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