198602600-9-17-2024-28-AS-RORN-D9NP5E-20241002110037

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602600
Report Date: 09/17/2024
Date Signed: 09/17/2024 02:34:55 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/13/2024 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240913133346

FACILITY NAME:	GOOD SHEPHERD COTTAGE ASSISTED LIVING		FACILITY NUMBER:	198602600
ADMINISTRATOR:	KLIEN,KATHRYN		FACILITY TYPE:	740
ADDRESS:	1218 ROYAL OAKS DR		TELEPHONE:	(626) 239-0710
CITY:	MONROVIA	STATE: CA	ZIP CODE:	91016
CAPACITY:	28	CENSUS: 20	DATE:	09/17/2024
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Nathan Nemeth - Administrative Assistant Sister Cecilia Marie, OCD, Care Assistant		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff caused injury to a resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced complaint visit to investigate the above mentioned allegation. LPA met with Nathan Nemeth, Administrative Assistant and explained the purpose of the visit. Shortly after, Sister Cecilia Marie, OCD, Care Assistant arrived and assisted LPA.

The investigation consisted of the following: LPA toured the facility's common areas and obtained/reviewed a copy of the Staff/Resident rosters and interviewed Staff #1 (S1)-Staff #2 (S2).

In regards to the allegation: "Staff caused injury to a resident." LPA interviewed Staff #1 (S1)-Staff #2 (S2) who stated that Resident/Alleged Victim is not a resident of the facility and have never been a resident of the facility. S1-S2 stated that some staff are aware of the allegation and the Resident/Alleged Victim resides in the other (RCFE) facility adjacent to this licensed facility. LPA reviewed the Resident roster (dated 09/09/2024) and resident is not listed on the roster. Therefore, the complaint was written for the wrong facility.

This agency has investigated the complaint alleging "Staff caused injury to a resident". Based on the information gathered during this visit, and the staff interviews, the allegation is deemed UNFOUNDED.
A finding of UNFOUNDED means that the allegation is either false, could not have happened, and/or is without a reasonable basis. We have therefore dismissed the complaint.

Exit interview conducted with Nathan Nemeth, Administrative Assistant and a copy of this report provided.

Unfounded

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

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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