198603340-10-25-2021-11-AS-MCAA-C8FUCB-20211104152741

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603340
Report Date: 10/25/2021
Date Signed: 10/25/2021 03:01:38 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/18/2021 and conducted by Evaluator Jade Jordan

COMPLAINT CONTROL NUMBER: 11-AS-20211018112050

FACILITY NAME:	FIDLER COTTAGE		FACILITY NUMBER:	198603340
ADMINISTRATOR:	AVILA, GLENDA		FACILITY TYPE:	740
ADDRESS:	2874 FIDLER AVE		TELEPHONE:	(424) 241-4625
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90815
CAPACITY:	6	CENSUS: 6	DATE:	10/25/2021
		UNANNOUNCED	TIME BEGAN:	10:08 AM
MET WITH:	Herbet Vivas		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility did not obtain converted room permit.

INVESTIGATION FINDINGS:

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On 10/25/21 Licensing Program Analyst (LPA) Jade Jordan conducted an Unannouced Complaint Inspection regarding the allegation above. LPA Spoke with Licensee/Administrator Heidi Skiles, and the purpose of the visit was explained.

Investigation consisted of the following: Physical plant tour including the garage, interviews with staff and Administrator, and requested resident roster.

Regarding Allegation : Facility did not obtain converted room permit.

Lpa observed the detached garage, there was unit build consistant of a studio sized room, with 4 enclosed walls, lighting and electricity. Inside there was a bed with no frame on the floor. Personal belongings of staff, space heater, and freestanding closet rack with clothing. LPA Spoke with the Hustband of Licensee Jake Skiles and he infomed LPA that they are currently in the process of submitting an Application with the city of Long Beach for a staff room, which will be used as a stafff break room. Mr. Skiles informed LPA that the city inspector has already come out, and that the facility will be moving forward with getting a permit.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021

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-20211018112050

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: FIDLER COTTAGE	FACILITY NUMBER: 198603340
	VISIT DATE: 10/25/2021

NARRATIVE

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At the time of inspection, no permit was available.
Therefore; “Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) us found to be SUBSTANTIATED. California Code Of Regulations, (Title 22, Division, Chapter #), are being cited on the attached LIC 9099 D.”)

An Exit interrview was conducted and a copy of this report was provided, along with appeal rights.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20211018112050

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: FIDLER COTTAGE	FACILITY NUMBER: 198603340
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/25/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/01/2021 Section Cited CCR 87305(a)	1 2 3 4 5 6 7	87305Alterations to Existing Building or New Facilities (a) P rior to construction or alterations, all facilities shall obtain a building permit.	1 2 3 4 5 6 7	Licensee will submit proof of permit application process, Including invoices, Sketches, proof of payment for permit. Submit an amended plan of operation if staff will continue to live in garage.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021

LIC9099 (FAS) - (06/04)

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