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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005757
Report Date: 03/22/2023
Date Signed: 03/22/2023 04:03:02 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 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
12/16/2022 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20221216140129
FACILITY NAME:IRVINE COTTAGE #11FACILITY NUMBER:
306005757
ADMINISTRATOR:NESBIT, MICHELLEFACILITY TYPE:
740
ADDRESS:24172 VIA LUISATELEPHONE:
(949) 533-5938
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 0DATE:
03/22/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Michelle Nesbitt, AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility failed to provide adequate care and supervision to resident, resulting in multiple falls while in care

A bed bug infestation is present in the facility

INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the allegations listed above.

An initial investigation visit was conducted on December 20, 2022. A tour of the physical plant was conducted, along with a review of complete resident records, facility log, staff schedule for the month of December, the current resident roster as well as the Medication Administration Records (MAR). LPA additionally conducted interviews with caregivers S1 and S2 and both administrators.

Two follow-up visits were conducted on February 16, 2023 and March 10, 2023. Facility was observed to be vacant with no residents at this time. Records were transferred to the licensee's corporate office. A phone interview with facility staff additionally confirmed that no facility logs were maintained after the current change of ownership was initiated.
CONTINUED ON FORM LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 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
12/16/2022 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20221216140129

FACILITY NAME:IRVINE COTTAGE #11FACILITY NUMBER:
306005757
ADMINISTRATOR:NESBIT, MICHELLEFACILITY TYPE:
740
ADDRESS:24172 VIA LUISATELEPHONE:
(949) 533-5938
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 0DATE:
03/22/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Michelle Nesbitt, AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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9
Staff mishandled a resident's medication while in care
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the allegations listed above.

An initial investigation visit was conducted on December 20, 2022. A tour of the physical plant was conducted, along with a review of complete resident records, facility log, staff schedule for the month of December, the current resident roster as well as the Medication Administration Records (MAR). LPA additionally conducted interviews with caregivers S1 and S2 and both administrators.

Two follow-up visits were conducted on February 16, 2023 and March 10, 2023. Facility was observed to be vacant with no residents at this time. Records were transferred to the licensee's corporate office. A phone interview with facility staff additionally confirmed that no facility logs were maintained after the current change of ownership was initiated.
CONTINUED ON FORM LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20221216140129
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: IRVINE COTTAGE #11
FACILITY NUMBER: 306005757
VISIT DATE: 03/22/2023
NARRATIVE
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CONTINUED FROM FORM LIC9099-A

Additional staff and witness interviews were conducted by LPA during the investigation.

Regarding the allegation that Staff mishandled a resident's medication while in care, the following has been concluded:
Facility provided LPA with Medication Administration Records for each residents during the initial investigation visit, which were noted to be filled in by staff present during the visit as well. However, upon further investigation, LPA was provided with photographic evidence that demonstrates that the actual administration status for medication may not have matched what was reported on the records. Medications for at least one of the five residents present at the time appeared to not have been administered as prescribed. As a result, the allegation is deemed to be Substantiated, meaning that the preponderance of evidence standard has been met.

A deficiency is cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted and a copy of this report along with appeal rights was provided to facility representative.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20221216140129
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: IRVINE COTTAGE #11
FACILITY NUMBER: 306005757
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/21/2023
Section Cited
CCR
87464(f)
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California Code of Regulations Section 87464(f) on Basic Services states that: "Basic services shall at a minimum include: (1) Care and supervision as defined in (...) Health and Safety Code [meaning] the facility assumes responsibility for, or provides or promises to provide ongoing assistance which includes (...)
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Licensee to conduct in-service training of staff assigned to the facility and ensure adequate assistance with medication self-administration is being provided upon re-opening of the location.
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assistance with taking medications,(...)." This requirement is not met as evidenced by: Medication packages observed to contain amounts of medication not corresponding to Administration Records. This poses a potential risk to the safety, health and personal rights of individual 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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20221216140129
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: IRVINE COTTAGE #11
FACILITY NUMBER: 306005757
VISIT DATE: 03/22/2023
NARRATIVE
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CONTINUED FROM FORM LIC9099

Additional staff and witness interviews were conducted by LPA during the investigation.

Regarding the allegation that Facility failed to provide adequate care and supervision to resident, resulting in multiple falls while in care, the following has been concluded:
Based on interviews and a review of resident records, residents R1 and R2 are confirmed to have both suffered fall incidents during their period of admission at the facility and have since been moved out by their responsible parties. The investigation was however not able to corroborate that the falls were directly attributable to a failure from facility staff to provide care and supervision. As a result, the allegation is deemed to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Regarding the allegation that A bed bug infestation is present in the facility, the following has been concluded:
Based on interviews conducted, observations made at the facility and a review of records provided including photographs, medical reports and invoices of pest extermination services, it was confirmed that one bed bug was found at the facility. After the discovery, measures which were all confirmed to be preventative in nature were taken to address the possibility of an infestation. Skin lesions observed on resident R2 were confirmed by a dermatologist to not be related to a possible presence of bed bugs, and no confirmed infestation was noted by the extermination service contracted by the facility. As a result, the allegation is deemed to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted and a copy of this report was provided to facility representative.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5