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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005828
Report Date: 09/16/2022
Date Signed: 09/16/2022 12:17:29 PM

Substantiated


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
11/04/2021 and conducted by Evaluator Albert Marin
COMPLAINT CONTROL NUMBER: 22-AS-20211104134318
FACILITY NAME:RAE'S COTTAGE AT BREAFACILITY NUMBER:
306005828
ADMINISTRATOR:ROCHE, LISAFACILITY TYPE:
740
ADDRESS:1306 W ALTA MESA DRIVETELEPHONE:
(714) 553-8292
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY:6CENSUS: 5DATE:
09/16/2022
UNANNOUNCEDTIME BEGAN:
11:14 AM
MET WITH:Administrator Lisa Roche TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff members are not adequately trained.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to this facility to deliver the findings for the investigation completed for the complaint filed against this facility last November 4, 2021. LPA met with Administrator (AD) Lisa Roche and stated the purpose of this visit,

Based on file review, observation, and interviews, the following are the findings. On November 12, 2021, LPAs Marin and Haley initiated the complaint investigation and observed two staff members on the floor with six residents in care. LPAs did a review on medication and medication assistance procedure of the facility. Facility had provided training to staff members but unable to provide proof of training on medications to support current trainings. Based on the above findings, the preponderance of the evidence standard has been met. Therefore, the above allegation is found SUBSTANTIATED.

Deficiency was observed. Citation was issued per Title 22 Division 6 of the California Code of Regulations.

LPA Marin conducted an exit interview with AD Roche. LPA discussed deficiency, citation issued and appeal rights. Copy of this report was left in the facility.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022
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-20211104134318
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: RAE'S COTTAGE AT BREA
FACILITY NUMBER: 306005828
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2022
Section Cited
CCR
87411(c)(3)(D)
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87411 Personnel Requirements - General. All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement was not met as evidenced by:
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Administrator will ensure that staff members complete the required training and training logs are up to date at all times. AD provided proof of training for the current staff members.
Citation cleared during the visit.
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Based on observation, interview and file review, facility missed to provide the initial and annual training as specified in HSC. Facility was unable to provide training logs for at least 1 staff member during 11/12/21 visit. This posed potential threat on the health and safety of residents in care.
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Note: LP provided cited regulation for full reference.

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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: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022
LIC9099 (FAS) - (06/04)
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