306005746-6-24-2022-22-AS-SSAS-CHVAWP-20220902003526

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005746
Report Date: 06/24/2022
Date Signed: 06/24/2022 01:34:51 PM

Unsubstantiated

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
06/04/2021 and conducted by Evaluator Patricia Velazquez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210604155001

FACILITY NAME:	IRVINE COTTAGE #14		FACILITY NUMBER:	306005746
ADMINISTRATOR:	TIZON, GERTRUDES		FACILITY TYPE:	740
ADDRESS:	19462 SIERRA CHULA		TELEPHONE:	(949) 725-0748
CITY:	IRVINE	STATE: CA	ZIP CODE:	92612
CAPACITY:	6	CENSUS: 6	DATE:	06/24/2022
		UNANNOUNCED	TIME BEGAN:	11:48 AM
MET WITH:	Alex Valle - Executive Director Michelle Nesbitt - Compliance Director		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident and a staff member was hit by another resident

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Patricia Velazquez conducted a subsequent complaint visit to investigate the above allegation and deliver the findings of the investigation. LPA Velazquez was allowed entry into the facility and met with Caregiver Rommel So and explained the purpose of the visit. Executive Director (ED) Alex Valle and Compliance Director (CD) Michelle Nesbitt arrived later to assist with the visit.

On today's visit LPA Velazquez conducted a tour of the physical plant along with CD Nesbitt. LPA also conducted interviews with a former caregiver as well as a current caregiver.

During the course of the investigation LPAs Ruth Martinez and Patricia Velazquez reviewed facility, staff, and resident records. LPAs Martinez and Velazquez also conducted interviews with the complainant, staff, a resident's family member, and residents. The individuals interviewed confirmed the incident occurred but did

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022

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 2

Control Number 22-AS-20210604155001

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 #14	FACILITY NUMBER: 306005746
	VISIT DATE: 06/24/2022

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

not actually witness the resident hit the other resident. One staff member did witness the resident hitting the other caregiver present on the day the incident occurred. The records reviewed included Physician's Reports, an Incident Report for the incident dated 05/28/2021, Hospice records, staff written statements regarding the incident, Centrally Stored Medication and Destruction Records, Functional Capability Assessments, Staff Training records, and Admission Agreements.

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 following allegation: Resident and a staff member was hit by another resident is deemed UNSUBSTANTIATED.

An exit interview was conducted with Executive Director Alex Valle and Compliance Director Michelle Nesbitt and a copy of this report along with the LIC 811s were provided at the time of this visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2