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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005753
Report Date: 01/18/2023
Date Signed: 01/18/2023 01:36:46 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
10/20/2022 and conducted by Evaluator Celine DePerio
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20221020170026
FACILITY NAME:IRVINE COTTAGE #8FACILITY NUMBER:
306005753
ADMINISTRATOR:VALLE, ALEJANDRAFACILITY TYPE:
740
ADDRESS:40 CYPRESS TREE LANETELEPHONE:
(949) 654-4370
CITY:IRVINESTATE: CAZIP CODE:
92612
CAPACITY:6CENSUS: 6DATE:
01/18/2023
UNANNOUNCEDTIME BEGAN:
12:36 PM
MET WITH: Facility Administrator-Michelle Nesbitt TIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff handled resident in a rough manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to this facility. LPA De Perio met with Facility Administrator, Michelle Nesbitt and stated the purpose of this visit which was to deliver the final findings for the complaint received on 10/20/22 against this facility.

This agency has investigated the complaint alleging that staff handled resident in a rough manner. LPA De Perio conducted file reviews and interviews of which the interviews conducted either stated that staff were “good” and that there were no safety concerns or witness of staff handling resident in a rough manner. The remainder of interviews were unable to be continued due to difficulty communicating, or individual denying wanting to be interviewed. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023
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-20221020170026
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 #8
FACILITY NUMBER: 306005753
VISIT DATE: 01/18/2023
NARRATIVE
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For today’s visit, no deficiencies were issued. No citations issued.

LPA De Perio conducted an exit interview with Facility Administrator, Michelle Nesbitt, and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2