198603177-4-17-2025-11-AS-SCIS-DHWV8F-20250623161240

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603177
Report Date: 04/17/2025
Date Signed: 04/17/2025 01:03:59 PM

Unfounded

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
04/16/2025 and conducted by Evaluator Pamela Bunker

COMPLAINT CONTROL NUMBER: 11-AS-20250416100930

FACILITY NAME:	CANTON COTTAGE		FACILITY NUMBER:	198603177
ADMINISTRATOR:	ROMAN, ELSA		FACILITY TYPE:	740
ADDRESS:	5221 E CANTON ST		TELEPHONE:	(818) 606-6136
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90815
CAPACITY:	6	CENSUS: 6	DATE:	04/17/2025
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Jose Umana		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff physically abused resident while in care.

INVESTIGATION FINDINGS:

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On 04/17/202 at 9:55 a.m., Licensing Program Analyst (LPA) Pamela Bunker conducted an initial visit on to gather information regarding the above allegation. LPA met with Licensee/Administrator Jose Umana, and the purpose of the visit was explained. LPA was granted entry to the facility.

Investigation consisted of the following: On 04/17/2025 at 9:50 a.m., the Department requested and reviewed the staff and resident's records and asked for copies of the following documents: Personnel Report (01/31/2025), Resident Roster (02/13/2025), Admission Agreement, Identification and Emergency Information, Physician's Report, Medical Assessment, Medication Administration Records (MARs), Consent Forms, Functional Capability Assessment, Preplacement Appraisal Information, Appraisal, Needs and Service Plan. Interviews were conducted with staff 1-2 (S1-S2) and resident 1-6 (R1-R6) all of whom denied the allegation. At 10:30 A.M., the department toured the facility buildings and grounds to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. We did not observe any signs of neglect or abuse during today's visit. See continued LIC9099-C page 2

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

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-20250416100930

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: CANTON COTTAGE	FACILITY NUMBER: 198603177
	VISIT DATE: 04/17/2025

NARRATIVE

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Continued LIC9099-C page 2

Allegation: Staff physically abused resident while in care.

The investigation revealed the following:
The investigation was initiated in response to an allegation that a staff member physically abused a resident while under the care of the facility. On April 17, 2025, the Department conducted interviews with staff members 1 and 2 (S1-S2) and residents 1 through 6 (R1-R6). All individuals interviewed stated that the alleged incident did not occur at Canton Cottage. They confirmed that no resident by the reported name resides at the facility, nor is there any staff member by that name employed at Canton Cottage, according to the resident roster, personnel and complaint reports.

However, S1 stated that a resident and staff matching the names mentioned in the complaint are currently located at Servato Cottage, a different facility. S1 stated that it is likely the complaint was mistakenly filed against the wrong facility.

A through review of the staff personnel records and resident roster at Canton Cottage confirmed that the individuals named in the complaint are not affiliated with this facility in any capacity.

S1-S2 and R1-R6 reported that residents are treated with dignity and respect in their interactions with staff and other individuals within the facility. S1-S2 stated that residents are provided with safe, healthful, and comfortable accommodations, to meet their individual needs.

S1-S2 stated that residents are free from corporal or unusual punishment, the infliction of pain, humiliation, intimidation, ridicule, coercion, threats, mental abuse, or any other punitive actions. This also includes protection from interference with daily living functions such as eating, sleeping, or toileting, as well as withholding shelter, clothing, medication, or aids to physical functioning.

R1-R6 stated they feel safe, and happy, and that the staff is providing residents with the necessary care and supervision to meet their needs.

See continued LIC9099-C page 3

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20250416100930

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: CANTON COTTAGE	FACILITY NUMBER: 198603177
	VISIT DATE: 04/17/2025

NARRATIVE

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Continued LIC9099-C page 3

This agency has investigated the complaint alleging Physical Abuse allegation. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint.

A copy of the Complaint Investigation Report LIC9099, and LIC9099-C, was provided to the Licensee/Administrator Jose Umana.

There were no deficiencies cited.

An exit interview was conducted

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

LIC9099 (FAS) - (06/04)

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