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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850074
Report Date: 04/21/2026
Date Signed: 04/21/2026 03:03:00 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
12/29/2025 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 29-AS-20251229112708
FACILITY NAME:COTTAGE INNFACILITY NUMBER:
565850074
ADMINISTRATOR:DANIA FAYYADFACILITY TYPE:
740
ADDRESS:191 WAYVIEW CTTELEPHONE:
(805) 650-7497
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:6CENSUS: 6DATE:
04/21/2026
UNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Judith GonzalezTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Staff did not follow resident's advance health care directive
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint visit for the above allegation. LPA met with Facility Staff/Designee Judith Gonzalez. Administrator was contacted via telephone and joined the visit telephonically. Entrance interview conducted.

During an initial complaint visit conducted on 01/06/2026, LPA interviewed staff from 11:13AM to 01:00PM, reviewed and obtained copies of relevant documents, and toured the physical plant at 02:03PM. Throughout the course of the investigation, interviewed Administrator telephonically, LPA attempted to interview three (3) additional relevant parties via telephone, and LPA reviewed all documents obtained. The following was then determined:

Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2026
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-20251229112708
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: COTTAGE INN
FACILITY NUMBER: 565850074
VISIT DATE: 04/21/2026
NARRATIVE
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The complaint alleges that Resident #1 (R1) had a Do Not Resuscitate (DNR) directive and the facility staff did not follow this directive when R1 was found unresponsive. LPA reviewed all documents for R1, which did include a DNR form signed by R1’s representative and R1’s physician dated 02/24/2024. Interview with staff and management revealed that facility staff were unaware that R1 had a DNR and the first time they saw this form was on the night R1 was found unresponsive. On 12/10/2025, staff entered R1's room at 12:00AM to assist R1 with repositioning and care needs and found R1 unresponsive. Staff dialed 9-1-1. Fire department personnel responded to the facility and began to treat R1. The licensee attempted to reach R1’s family members to inform them of the situation, however, neither family member answered their phone. Fire personnel also attempted to reach R1’s family and were successful after about 20 minutes of treatment. It was then R1’s family member informed the fire personnel about R1’s DNR. According to staff, while on the phone with R1’s family member, fire personnel were able to locate R1’s DNR, possibly in R1’s room.

Staff interviews revealed that each resident has an emergency folder, which contains all pertinent documents, including, but not limited to: medication list, medical assessment, consent for treatment, insurance information, as well as physician contact information and the DNR form if the resident has one on file. LPA observed the emergency folder for R1, which did not contain a copy of the DNR form. Staff interviews revealed that two (2) other residents in the facility have DNR forms and LPA confirmed the presence of the DNR forms in both these residents’ emergency folders. R1’s Admission Agreement indicated “I acknowledge the receipt of the facility’s policies on DNR orders,” which R1’s family member initialed upon admission to the facility. The facility’s policy indicates any DNR form is required to be given to facility management upon move in. All staff interviewed at the facility stated they had never personally received a DNR form from R1’s family, nor were the staff aware that R1 had a DNR form. However, R1’s family member indicated this form was submitted by another family member to the facility management along with R1’s other admission documents. LPA attempted to reach the fire personnel to confirm the details surrounding the night of the incident, however, LPA was unable to obtain any clarifying information. Although it appears R1 did have a DNR form, which was present in the facility, it is unclear whether the document was directly given to the facility staff per the facility policy. Based on the conflicting information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. 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 above allegation is deemed UNSUBSTANTIATED at this time.

No citations issued. Exit interview conducted. Today's report was reviewed and a copy provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2026
LIC9099 (FAS) - (06/04)
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