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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005744
Report Date: 08/24/2021
Date Signed: 08/24/2021 03:48:23 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/18/2021 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20210818143734
FACILITY NAME:IRVINE COTTAGE #10FACILITY NUMBER:
306005744
ADMINISTRATOR:VALLE, ALEJANDRAFACILITY TYPE:
740
ADDRESS:24332 SPARTAN STTELEPHONE:
(949) 458-6083
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
08/24/2021
UNANNOUNCEDTIME BEGAN:
02:38 PM
MET WITH:Michelle NesbitTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff failed to safeguard resident's personal belongings
INVESTIGATION FINDINGS:
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad to investigate the above-mentioned complaint allegation. LPA met with Compliance Manager (CM) Michelle Nesbit, discussed the purpose of the inspection, explained the allegation, and conducted the investigation.

The investigation into the allegation that Staff failed to safeguard resident's personal belongings revealed the following: During the course of the investigation, LPA inspected the facility, interviewed CM, facility staff, and residents, and reviewed facility files. Interviews with CM and facility staff revealed that Resident #1 (R1) came to the facility with two walkers. One of the walkers was stored in the garage but, possibly after the garage was recently cleaned out, facility staff could no longer locate R1’s second walker that was stored in the garage. Thus, the allegation is determined to be substantiated. CM stated that the facility is providing R1 with a replacement walker and is also instituting a new policy that all walkers and wheelchairs be labeled to avoid potential misplacement in the future. (Page 1)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
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 22-AS-20210818143734
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: IRVINE COTTAGE #10
FACILITY NUMBER: 306005744
VISIT DATE: 08/24/2021
NARRATIVE
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During the course of the investigation, CCLD obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report as well as appeal rights was left at the facility. (Page 2, End)
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20210818143734
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: IRVINE COTTAGE #10
FACILITY NUMBER: 306005744
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/07/2021
Section Cited
CCR
87217(b)
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87217 Safeguards for Resident Cash, Personal Property, and Valuables … (b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables ... This requirement was not met as evidenced by:
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The licensee stated they are replacing R1's walker and also instituting a new policy that all walkers and wheelchairs be labeled to avoid potential misplacement in the future. LPA reviewed policy and confirmed correction during today's inspection.
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Based on interviews and observations, the licensee did not safeguard R1’s walker which was lost, which poses a potential personal rights risk to persons in care.
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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: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3