198603177-7-22-2024-11-AS-SCIS-D9GPKG-20240926112303

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603177
Report Date: 09/19/2023
Date Signed: 07/22/2024 11:06:07 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
02/13/2023 and conducted by Evaluator Pamela Bunker

COMPLAINT CONTROL NUMBER: 11-AS-20230213132727

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: 4	DATE:	09/19/2023
		UNANNOUNCED	TIME BEGAN:	07:30 AM
MET WITH:	Jose Umana & Edgar Yraheta		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained fracture while in care
Facility failed to meet reporting requirements
Facility did not notify resident's POA of an incident.
Facility failed to meet resident's needs

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Tuesday, September 19, 2023. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. LPA Bunker met with Licensee Jose Umana and Administrator Elsa Roman. LPA Bunker explained the purpose of today's visit.
The investigation consisted of the following: During the course of the investigation Interviews were conducted with staff 1-6 (S1-S6) and residents 2-5 (R2-R5). LPA Bunker asked questions relevant to the nature of the complaint. During the visits on 02/14/2023 and 09/19/2023, we toured the entire 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 the visits. We observed and reviewed the resident’s folder, physician's report, medical records, admission agreement, I.D. and emergency information, medication, medication log, medical assessment, consent forms, appraisal & needs service plan. LPA Bunker requested copies of supporting documents. See continued LIC9099-C page 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

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-20230213132727

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: 09/19/2023

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

Continued LIC9099-C page 2

Allegation #1: Resident sustained a fracture while in care. Staff members 1-6 (S1-S6) stated resident sustained a fracture while in care from a fall. The facility had no control over the fall and could not have prevented the resident from falling. The resident was in his bedroom in his recliner chair after breakfast and had an unwitnessed unforeseen fall. The facility staff immediately went to the resident's bedroom to check on the resident and provided assistance. The hospice nurse called 911 immediately and paramedics transported the resident to the hospital where he was diagnosed with a left femur fracture. S1-S6 stated that the facility staff are well-trained, adhere to Title 22 Regulations, and took all necessary precautions.

Allegation #2: Facility failed to meet report requirements
Staff 1-6 (S1-S6) members interviewed stated a written special incident report (SIR) was reported and submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence. Staff 1-2 (S1-S2) stated this report includes the resident's name, age, sex, date of admission; date and nature of the event; attending physician's name, findings, and treatment, and disposition of the case. S1-S2 stated a follow-up SIR was also reported regarding the death of the resident, the cause of death, and where the death occurred. S1-S2 stated that the incident did not occur because of neglect and lack of supervision. S1-S6 stated staff could not have prevented the fall from happening. S1-S6 denied the allegation.

Allegation #3: The facility did not notify the resident's POA of an incident
Staff 1-6 (S1-S6) stated that the facility gave the resident’s information to the paramedics and Long Beach Memorial Hospital. The hospice nurse and Administrator came to the facility immediately after the resident had fallen. The Hospice nurse and the Administrator informed the resident POA of the incident. The staff is not aware of how long it took the POA to locate the resident. The Administrator stated they give the paramedics the resident, physician reports, medications, and contact information. The Administrator stated they reported the Special Incident Report and informed Community Care Licensing and all the appropriate agencies in a timely manner.

See continued LIC9099-C page 3

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20230213132727

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: 09/19/2023

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

Continued 9099-C page 3

Allegation #4: Failed to meet resident's needs
Staff 1-6 (S1-S6) stated the facility staff did not fail to meet the resident's needs. S1-S6 stated staff went to the resident's bedroom and immediately provided assistance to make sure the resident was okay. S1-S6 stated the facility staff are providing residents with care and supervision as necessary to meet the resident's needs. S1-S6 stated they assist residents with their daily needs.

Investigation revealed the following: Staff 1-6 (S1-S6), stated that on 01/29/2023, not sure of the exact time. The resident was in his bedroom sitting in his recliner chair after breakfast and had an unwitnessed unforeseen fall. The facility staff immediately checked on the resident. The resident reported pain in his left hip area. Staff contacted the administrator, the hospice nurse, and 911. The resident was transported by paramedics to Long Beach Memorial Hospital where he was diagnosed with a left femur. The resident had surgery which was successful, however, the resident did not regain consciousness after the procedure. The resident was placed on palliative care and passed away at the hospital. S1-S6 and residents 2-5 (R2-R5) interviewed denied the allegations. S1-S6 stated that the incident did not occur because of neglect or lack of care and supervision. S1-S6 stated staff couldn't have prevented the resident from falling. It was not the staff’s fault and it was an accident. S1-S6 stated that the facility staff are well-trained and competent, adhere to Title 22 Regulations, and took all necessary precautions.

Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. 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 deemed unsubstantiated.

A copy of the Complaint Investigation Report LIC9099, and LIC9099-C, was provided to Administrator. There were no deficiencies cited. Exit interview conducted.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3