198603249-6-5-2025-11-AS-UCOL-DHTU62-20250620151739

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603249
Report Date: 06/05/2025
Date Signed: 06/05/2025 09:54:32 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/21/2025 and conducted by Evaluator Regina Cloyd

COMPLAINT CONTROL NUMBER: 11-AS-20250421145304

FACILITY NAME:	CERVATO COTTAGE		FACILITY NUMBER:	198603249
ADMINISTRATOR:	UMANA, JOSE		FACILITY TYPE:	740
ADDRESS:	4622 E. CERVATO STREET		TELEPHONE:	(818) 606-6136
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90815
CAPACITY:	6	CENSUS: 5	DATE:	06/05/2025
		UNANNOUNCED	TIME BEGAN:	09:16 AM
MET WITH:	Edgar Yraheta		TIME COMPLETED:	10:05 AM

ALLEGATION(S):

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Staff physically abused resident while in care.

INVESTIGATION FINDINGS:

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On 04/22/2025, Licensing Program Analyst (LPA) Jose Anguiano conducted an unannounced complaint investigation for the allegation listed above. On 05/08/25, LPA Regina Cloyd conducted a subsequent visit to gather information regarding the above allegation. On 06/05/25, LPA Cloyd met with Administrator Assistant Edgar Yraheta to deliver findings.

Investigation consisted of the following: On 04/22/25, LPA requested the following documents: Personnel Report/ Staff Schedule (LIC500), Resident Roster (LIC9020), Resident (R1-R2) Admission Agreements, 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, Staff (S1-S2) Personnel Records which includes Personnel Record (LIC501), and Training Records. On 05/08/25, LPA interviewed two residents (R2 - R3), the Administrator (S1), three caregivers (S2 – S4), four witnesses (W1 – W4), and reviewed R1’s Los Alamitos Medical Center record and medication records. Continue to LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

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 11-AS-20250421145304

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CERVATO COTTAGE	FACILITY NUMBER: 198603249
	VISIT DATE: 06/05/2025

NARRATIVE

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LPA observed photo of R1’s bruise and prescription order to discontinue medication. LPA attempted to interview R1 and observed bedrails. On 05/10/25, LPA Cloyd received Nurse Practitioner notes dated 04/07/25 from MedWell Medical. On 06/04/25, LPA reviewed Community Care Licensing (CCL) Clinical Consultant’s Report on R1’s medical documents.

Investigation revealed the following:

Regarding the allegation, “Staff physically abused resident while in care,” it is being alleged that Resident #1 (R1) sustained bruises across R1’s rib cage and hip. Record review of CCL Clinical Consultant’s Report revealed R1 was prescribed medication for an old diagnosis and that medication can cause bruising. R1 has left upper chest wall bruising towards the abdominal area, radiating to the bilateral flank area (MedWell Nurse Practitioner’s notes 04/07/25 and Los Alamitos Medical Center 04/15/25). Record review of R1’s prescription order revealed that the medication was discontinued on 04/10/25. Four out of four staff (S1 – S4) interviews denied the allegation. Staff (S1 – S3) indicated that R1 tries to get out of bed and could have obtained the bruises from the half bed rail. Interview with W1, R1’s son-in-law, indicated that the physician assistant said the bruises could have appeared from R1’s internal bleeding. Interview with R2 – R3 indicated that they like the quality of care and have not been physically abused while in care. Two out of three witnesses (W2-W4) indicated that their family member hasn’t sustained a bruise due to physical abuse.

Regarding the allegation, “Staff physically abused resident while in care,” based on record reviews, interviews, and observations, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies issued.

An exit interview was conducted and a copy of this report was provided to the Administrator Assistant Edgar Yraheta.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

LIC9099 (FAS) - (06/04)

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