198600990-12-16-2022-11-AS-JHAD-CNN6KC-20230201195230

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600990
Report Date: 11/01/2022
Date Signed: 12/16/2022 02:36:27 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
08/10/2022 and conducted by Evaluator Jeremiah Randle

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220810111658

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: 4	DATE:	11/01/2022
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Fetima Dinsmore House Mgr		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility is interfering with resident's ability to have visitors.

INVESTIGATION FINDINGS:

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This report serves as an amendment to clarify findings, it does not supersede the complaint investigation findings reflected on report created on 8-17-2022

On 8/17/2022 at 9:30a.m. Licensing Program Analyst (LPA) Jeremiah Randle conducted an unannounced visit to deliver the findings 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.

The investigation consisted of the following:
LPA conducted observation of physical plant, Resident Interview (R1), Staff Interviews (S1-S7), and R1’s Facility File, LPA obtained copies of Pertinent documents pertaining to the allegation. LPA requested from the facility (Admissions Agreement, House Rules, Physicians Report /Medical Records, Client Roster, Staff Roster) Needs and Services, Functional Capability Assessment, SIR’s/SOC 341, staff / nursing notes and Police Reports if any. Resident(s) file(s) for Resident 1(victim) inclusive of all documents.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Jeremiah Randle
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022

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-20220810111658

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: 11/01/2022

NARRATIVE

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Cont.

Investigation Revealed the following.

Regarding Allegation: Facility is interfering with resident's ability to have visitors.

It was alleged that facility is not allowing visitation. Reporting party called CCL to report that resident (R1) was not being allowed visitors. On August 17, 2022 LPA interviewed Licensee Brenda Chandler (S1). LPA asked S1 if she was aware of the allegation Facility is interfering with resident's ability to have visitors. S1 denied the allegation and had staff provide a copy of the COVID screening signature page. S1 stated that S1 met with C1 while they were visiting with visitors. LPA also met with (S 2-7) all denied interference of visitation with any clients.

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.

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 UNSUBSTANTIATED.

Exit interview was conducted with the Administrator Kim Post and a copy of this report was provided.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Jeremiah Randle
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022

LIC9099 (FAS) - (06/04)

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