198602568-5-21-2025-11-AS-RORN-DHJVFM-20250611162410

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602568
Report Date: 05/21/2025
Date Signed: 05/21/2025 04:17:55 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
05/13/2025 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20250513143305

FACILITY NAME:	MOM & DAD'S HOUSE-COTTAGE		FACILITY NUMBER:	198602568
ADMINISTRATOR:	MEADER, IVONNE A		FACILITY TYPE:	740
ADDRESS:	5413 E CONANT ST		TELEPHONE:	(949) 381-1792
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90808
CAPACITY:	6	CENSUS: 6	DATE:	05/21/2025
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Elsa Roman		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff mismanaged resident's medication

INVESTIGATION FINDINGS:

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On 05/21/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Complaint Visit to the facility listed above. LPA met with Administrator/Licensee, Ivonne Meader and Administrator, Elsa Roman, and the purpose of today’s visit was explained. LPA was granted entry into the facility.

The investigation consisted of the following:
During today's visit, LPA inspected the facility, conducted a medication review, interviewed Staff S1-S4, interviewed residents R1, R3-R5, interviewed Resident’s R1, R2, and R5’s Responsible Party W1- W3, and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Physician’s Reports, Physician Orders, Centrally Stored Medications, Medication Exceptions, PRN Report, Staff Training Logs, and Medication Administration Record (MAR) for March and April 2025.

The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025

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 3

Control Number 11-AS-20250513143305

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: MOM & DAD'S HOUSE-COTTAGE	FACILITY NUMBER: 198602568
	VISIT DATE: 05/21/2025

NARRATIVE

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Allegation: Staff mismanaged resident's medication
The allegation alleges that resident’s medication is not properly logged or not logged in the resident file.

LPA observed centrally stored medications secured in a locked medication cart. All medications were observed in their original packaging. From 11:51 AM to 12:32 PM, LPA reviewed Resident R1-R6’s Physician’s Orders and Centrally Stored Medications and observed the medication bubble packs are consistent with the dates and listed medications from the pharmacy and physician.

LPA received and reviewed resident Medication Exception that indicates when, why, and who provided or withheld medication. LPA received and reviewed residents PRN Report that indicates the date and time a PRN was given, the strength, reason, result and who gave the medication. LPA received and reviewed the Staff training regarding medication administration and medication procedure regarding physician orders, documenting, and labels. LPA observed staff conduct 7 hours of medication training annually.
During interviews with Staff S1-S4, were asked if residents receive their medications as prescribed, four (4) out of four (4) stated residents receive their medications as prescribed. Additionally, Staff S1-S4 were asked if there has been any mismanagement of medications, four (4) out of four (4) stated no, there have been no medication mismanagement and medications are provided as prescribed.
During interviews with Residents R1, R3-R5, were asked if they receive their medication as prescribed, four (4) out of four (4) stated yes, they receive their medications as prescribed.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 11-AS-20250513143305

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: MOM & DAD'S HOUSE-COTTAGE	FACILITY NUMBER: 198602568
	VISIT DATE: 05/21/2025

NARRATIVE

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During interviews with Resident R1, R2, and R5’s responsible party and/or family member W1- W3 were asked if their resident receives their medications as
prescribed, three (3) out of three (3) stated their residents receive their medications as prescribed.

During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

LPA did not observe or cite any deficiencies during today's visit.

An exit interview was conducted with Licensee/Administrator, Ivonne Meader, and Administrator, Elsa Roman, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025

LIC9099 (FAS) - (06/04)

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