565801505-11-26-2024-29-AS-KHEN-DBEVAR-20241127151623

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801505
Report Date: 11/26/2024
Date Signed: 11/26/2024 12:51:14 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/21/2024 and conducted by Evaluator Kelly Dulek

COMPLAINT CONTROL NUMBER: 29-AS-20241121091701

FACILITY NAME:	FAMILYCARE COTTAGE ONE		FACILITY NUMBER:	565801505
ADMINISTRATOR:	CHRISSY CORTEZ		FACILITY TYPE:	740
ADDRESS:	820 CALLE CEDRO		TELEPHONE:	(805) 492-1200
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 6	DATE:	11/26/2024
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Marisol Flamenco, Facility Designee		TIME COMPLETED:	12:55 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff falsify training records
Staff do not ensure facility is free from pests
Dishwasher is in disrepair

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint investigation for the allegations listed above. LPA arrived at the facility at 11:15AM and was greeted by facility staff. LPA met with Facility Designee Marisol Flamenco. Entrance interview conducted.

During today’s visit, LPA interviewed staff and Facility Designee from 11:17AM to 11:55AM, toured the facility with Facility Designee at 11:57AM and LPA reviewed and obtained copies of pertinent documents. The following was then determined:

Allegation "Staff falsify training records:"
The complaint alleges that staff are not trained annually as required. LPA interviewed facility staff, who indicated they are trained as required. Staff indicated they have completed trainings and that hospice nurses

Report Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 11/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024

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 29-AS-20241121091701

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FAMILYCARE COTTAGE ONE	FACILITY NUMBER: 565801505
	VISIT DATE: 11/26/2024

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

and facility staff provide ongoing training. LPA observed training binders including signed documents indicating staff have received training monthly. During the visit, LPA and Facility Designee attempted to contact the hospice nurse who provided most training, however nurse was unavailable. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation “staff falsify training records” is deemed UNSUBSTANTIATED at this time.

Allegation "Staff do not ensure facility is free from pests:"
During the facility tour, LPA observed a rodent trap in the garage, but no droppings or other evidence of pest infestation. Facility Designee indicated that the facility has ongoing monthly pest control as a preventative measure against pests, which includes the rodent trap observed. LPA observed all kitchen cabinets, crevices, and behind all appliances and did not observe any insects or droppings. Staff interviewed indicated they had in the past seen pests, but not recently. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation “staff do not ensure facility is free from pests” is deemed UNSUBSTANTIATED at this time.

Allegation "Dishwasher is in disrepair:"
Interview with Facility Designee revealed that management had purchased a new dishwasher for the facility about 1 year ago. The dishwasher is functional, but that facility staff choose to wash most dishes by hand. During the visit, the Facility Designee turned on the dishwasher at 12:05PM and LPA observed the dishwasher to be functional at the time of the visit. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation “dishwasher is in disrepair” is deemed UNSUBSTANTIATED at this time.

No citations issued. Exit interview conducted. A copy of today's report was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 11/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2