198603225-9-20-2024-28-AS-DSIS-D9QTPM-20241004145434

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603225
Report Date: 09/20/2024
Date Signed: 09/20/2024 01:15:50 PM

Unsubstantiated

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
09/16/2024 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240916115742

FACILITY NAME:	CRISTO REY COTTAGE ASSISTED LIVING		FACILITY NUMBER:	198603225
ADMINISTRATOR:	KLEIN, KATHRYN		FACILITY TYPE:	740
ADDRESS:	1216 ROYAL OAKS DRIVE		TELEPHONE:	(626) 408-7802
CITY:	MONROVIA	STATE: CA	ZIP CODE:	91016
CAPACITY:	28	CENSUS: 22	DATE:	09/20/2024
		UNANNOUNCED	TIME BEGAN:	09:24 AM
MET WITH:	Sister Magdalene Grace, OCD - BSN Care Coordinator		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Staff physically abused resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent complaint visit to investigate the above allegation and deliver finding. LPA met with Sister Magdalene Grace, OCD, BSN Care Coordinator and discussed the purpose of today's visit.

During the initial visit on 09/17/2024, LPA conducted a tour of the facility's common areas and
obtained/reviewed copies of Resident & Staff Rosters, Resident #1 (R1) files, Care notes, Podiatrist appointment/notes/instructions, Unusual Incident/Injury Report (Nov. 2022-Mar. 2024), Hospital contusion notes/instructions, Medication Review Report and photo of R1's bruised right foot. LPA also obtained copies of Staff #6 (S6) files. LPA interviewed Staff #1 (S1) - Staff #3 (S3) and telephonically interviewed Staff #4 (S4). On 09/18/2024, LPA telephonically interviewed Staff #5 (S5) - Staff #6 (S6).

During today's visit, LPA conducted a tour of the facility and obtained copies of Resident & Staff Rosters, and R1's Podiatry Progress Notes (09/11/2024). LPA interviewed Resident #1 (R1) - Resident #5 (R5). *****CONTINUED ON LIC9099-C*****

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

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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Control Number 28-AS-20240916115742

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: CRISTO REY COTTAGE ASSISTED LIVING	FACILITY NUMBER: 198603225
	VISIT DATE: 09/20/2024

NARRATIVE

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The investigation reveals the following:

In regards to the allegation: “Staff physically abused resident in care.” It is alleged that R1 may have been physically abused by a staff due to bruising, discoloration and swelling observed on R1's right foot. (6) of (6) staff interviewed denied the allegation and stated that they care for the residents and would never harm them. S6 stated that if R1 was stomped on her foot, she would have screamed and other staff could have heard her due to the proximity of her bedroom to the kitchen where staff are present at all times. Based on file reviews and interviews, on 9/07/2024, while R1 was being assisted by S4, R1 was slowly slipping down and was lowered to the floor to sit, no noted injury. The following day, S2 and S6 were assisting R1, when S2 noticed that R1's right foot toes were bruised. Staff reported it to S3 and provided first aid on R1 but no hospitalization required. On 9/09/2024, S1 promptly made a podiatry appointment for R1. And on 9/11/2024, R1 was seen by the podiatrist and had her ingrown toenail removed. Doctor's notes indicated that R1 fell and hurt her foot, with the right big toe being the site of the ingrown toenail. Documentation reviewed revealed that R1 has history of falls and contusion. (4) out of (5) interviewed residents denied the allegation and stated that the staff/caregivers are caring and have never caused harm to them. (5) out of (5) residents stated that they feel safe and comfortable in the facility. During the visit, LPA observed that R1's room is located next to the kitchen where (2) staff members are working. Based on documentation reviewed and interviews conducted with residents and staff, there was not enough supportive evidence to corroborate 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 UNSUBSTANTIATED.

Exit interview and a copy of this report was provided to Sister Magdalene Grace, OCD, BSN Care Coordinator.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

LIC9099 (FAS) - (06/04)

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