361880626-12-6-2021-18-AS-EMAN-CDPSJJ-20220421135513

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880626
Report Date: 12/06/2021
Date Signed: 12/06/2021 12:36:09 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/29/2021 and conducted by Evaluator Stephanie Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20211129131125

FACILITY NAME:	JCP COTTAGE		FACILITY NUMBER:	361880626
ADMINISTRATOR:	FRISCO SANRY		FACILITY TYPE:	740
ADDRESS:	14241 LA MIRADA ST		TELEPHONE:	(949) 769-9626
CITY:	VICTORVILLE	STATE: CA	ZIP CODE:	92392
CAPACITY:	6	CENSUS: 2	DATE:	12/06/2021
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Frisco Sanry		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Administrator did not designate appropriate personnel in their absence
Facility is not meeting food service requirements
Resident's property was not safeguarded
Facility does not provide activities for residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility in order to initiate a complaint investigation into the above allegations. Upon arrival, LPA Williams introduced herself to Administrator, Frisco Sanry, who was also informed of the purpose of the visit. The investigation consisted of direct observations, records review, and interviews with staff and residents.

In regards to allegation #1, LPA Williams interviewed Staff #1 (S1) who stated that a Designation of Facility Responsibility form (LIC 308) was submitted to the regional office prior to S1 leaving the country from 11/15/2021-11/29/2021. LPA Williams confirmed that the form was received by the regional office on 11/9/2021.

In regards to allegation #2, LPA Williams interviewed S1, who stated that Staff #2 (S2) and Staff #3 (S3) were trained on providing adequate food service to the residents. S1 stated that prior to S1 leaving the country, S1 observed that S2 and S3 provided adequate food service; however, S1 stated that S1 could not detail the food service provided by S2 and S3 while S1 was away. S1 denied that the facility is not providing adequate meal

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20211129131125

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: JCP COTTAGE	FACILITY NUMBER: 361880626
	VISIT DATE: 12/06/2021

NARRATIVE

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food service provided by S2 and S3 while S1 was away. S1 denied that the facility is not providing adequate meal portions, and stated that the residents receive three meals a day plus snacks in between meals. S1 denied that there are expired foods in the facility's food supply and that the meals are nutritious with various meats and vegetables provided to the residents. LPA Williams interviewed Resident #1 (R1) and Resident #2 (R2), who both stated that the facility is providing adequate food service. In regards to meal portions, R1 stated that they can be small at times; however, second portions of food may be requested. LPA Williams observed a sufficient supply of perishable and non-perishable food supply. LPA Williams also observed that items in the food supply did not appear expired nor unpalatable.

In regards to allegation #3, LPA Williams interviewed S1 who stated that there was an incident in the past where resident's clothing items were co-mingled in the laundry; however, S1 stated that there have been steps taken to prevent another incident such as this. S1 denied that the residents property is not being safeguarded. LPA Williams interviewed R1 and R2 who denied that their property is not being safeguarded.

In regards to allegation #4, LPA Williams interviewed S1 who stated that there are various activities for the residents, including board games, puzzles, and exercising. LPA Williams interviewed R1, who stated that the facility does provide activities for the residents. LPA Williams interviewed, R2, who stated that they choose not to participate in activities provided by the facility.

Based on evidence obtained during today’s visit, LPA Williams has determined that the above allegations are UNSUBSTANTIATED; meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where this report (LIC 9099) was discussed and a copy was provided to the Administrator at the completion of the visit.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021

LIC9099 (FAS) - (06/04)

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