<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601844
Report Date: 02/05/2025
Date Signed: 03/10/2025 02:26:10 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/28/2025 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20250128152452
FACILITY NAME:PEPPERWOOD AVENUE FACILITYFACILITY NUMBER:
198601844
ADMINISTRATOR:DAVENPORT, RENEEFACILITY TYPE:
735
ADDRESS:4735 PEPPERWOOD AVETELEPHONE:
(562) 982-4237
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY:3CENSUS: 3DATE:
02/05/2025
UNANNOUNCEDTIME BEGAN:
08:59 AM
MET WITH:ADMINISTRATOR JOLANDA CARTRIDGETIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff yells at resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
This report supersedes the report dated 02/05/2025. The investigation findings have not changed from Substantiated.
On 02/05/2025 Community Care Licensing Division (CCLD) conducted an unannounced visit to the facility Pepperwood Avenue Facility and was greeted by Administrator Jolanda Cartridge (S1). CCLD staff explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.

Investigation consisted of the following: CCLD staff interviewed Administrator Jolanda Cartridge S1, 3 out of 3 residents (R1-R3), 3 out of 3 staff (S1-S3). On 02/05/2025 CCLD staff obtained and reviewed copies of the following records: Activity log notes (date 1/16, 1/17, 1/27/2025), Physician Report (dated 10/16/2023) for R1-R3. Needs and Service Plan (date 7/23/2024) for R1-R3. CCLD staff toured the facility with S1.

The investigation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 11-AS-20250128152452
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PEPPERWOOD AVENUE FACILITY
FACILITY NUMBER: 198601844
VISIT DATE: 02/05/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding Allegation #1: Staff yells at resident.

It is being alleged that staff yelled at resident. During the investigation CCLD staff toured the facility and noted no negative interactions between staff and residents. Interviews indicate the following: S1 indicates that staff do not yell at residents. 2 out of 3 staff indicate that they have not witnessed staff yelling at residents. 1 out of 3 staff have witnessed staff yelling at residents. 2 out of 3 residents indicate that staff has yelled at them many times. 1 out of 3 residents non-verbal and could not be interviewed.

Based on records review observations and interviews, the preponderance of evidence standard has been met; therefore, the allegation of “staff yells at resident” is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099D.

An exit interview was conducted, and plan of correction were developed. A copy of the Complaint Report and appeals rights were provided to the Administrator Jolanda Cartridge S1.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20250128152452
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: PEPPERWOOD AVENUE FACILITY
FACILITY NUMBER: 198601844
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/14/2025
Section Cited
CCR
80072
1
2
3
4
5
6
7
80072(a)(1)Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:(1) To be accorded dignity in his/her personal relationships with staff and other persons.
1
2
3
4
5
6
7
Administrator will submit in service training for all staff regarding treating clients with dignity and respect by POC due date. Administration my submit proof via email
8
9
10
11
12
13
14
This standard was not met as evidenced By: Interviews revealed Staff1 yelled at client in care


8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/28/2025 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20250128152452

FACILITY NAME:PEPPERWOOD AVENUE FACILITYFACILITY NUMBER:
198601844
ADMINISTRATOR:DAVENPORT, RENEEFACILITY TYPE:
735
ADDRESS:4735 PEPPERWOOD AVETELEPHONE:
(562) 982-4237
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY:3CENSUS: 3DATE:
02/05/2025
UNANNOUNCEDTIME BEGAN:
08:59 AM
MET WITH:ADMINISTRATOR JOLANDA CARTRIDGETIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff inappropriately records resident
Staff does not allow resident to do outside activities
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 02/05/2025 Community Care Licensing Division (CCLD) conducted an unannounced visit to the facility Pepperwood Avenue Facility and was greeted by Administrator Jolanda Cartridge (S1). CCLD staff explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.

Investigation consisted of the following: CCLD staff interviewed Administrator Jolanda Cartridge S1, 3 out of 3 residents (R1-R3), 3 out of 3 staff (S1-S3). On 02/05/2025 CCLD staff obtained and reviewed copies of the following records: Activity log notes (date 1/16, 1/17, 1/27/2025), Physician Report (dated 10/16/2023) for R1-R3. Needs and Service Plan (date 7/23/2024) for R1-R3. CCLD staff toured the facility with S1.

The investigation revealed the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20250128152452
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PEPPERWOOD AVENUE FACILITY
FACILITY NUMBER: 198601844
VISIT DATE: 02/05/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding Allegation #1: Staff inappropriately records resident.

It is being alleged that staff records residents’ conversations. During the investigation CCLD staff toured the facility and noted no negative interactions between staff and residents. Record reviews indicate the following: R1-R3 Physician Report date 10/16/2023 indicates that residents has cognitive issues. Interviews indicate the following: S1 indicates that no staff records any residents’ conversations. 3 out of 3 staff indicate that no staff records residents’ conversations. 1 out of 3 residents indicate that staff records resident conversations with staff cell phone, but resident does not have any proof. 1 out of 3 resident indicates that staff does not record resident conversations. 1 out of 3 residents non-verbal and could not answer any questions.

Regarding Allegation #2: Staff does not allow resident to do outside activities.

This complaint alleged that staff did not take residents to outside activities. During the investigation CCLD staff toured the facility and noted no negative interactions between staff and residents. Record reviews indicate: The facility ’s Physician Report (date 10/16/2023) for R1-R3 not able to leave facility unassisted. Activity log records (date 1/16, 1/17, 1/27/2025) for R1-R3 indicate that staff took residents to activities outside the facility. Interviews indicate the following: A1 indicated that staff do take residents outside the facility when the residents request to be taken outside the facility. 3 out of 3 staff indicate that staff does take residents outside the facility when requested. 1 out of 3 residents indicate that staff do not take residents outside facility when requested.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegations of “staff inappropriately records residents”, “staff does not allow residents to do outside activities”, is found to be UNSUBSTANTIATED.


An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Jolanda Cartridge S1.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5