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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850074
Report Date: 03/09/2022
Date Signed: 03/09/2022 11:34:10 AM



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
04/26/2021 and conducted by Evaluator Joann Rosales
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20210426114434
FACILITY NAME:COTTAGE INNFACILITY NUMBER:
565850074
ADMINISTRATOR:KATAPODY, GEORGIAFACILITY TYPE:
740
ADDRESS:191 WAYVIEW CTTELEPHONE:
(805) 650-7497
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:6CENSUS: 6DATE:
03/09/2022
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Cinthia MezaTIME COMPLETED:
11:33 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Provider did not reach out to the resident's reponsible party
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) JoAnn Rosales conducted a subsequent unannounced complaint visit to this facility for the above complaint allegation to deliver final investigation findings. LPA met with Administrator Cinthia Meza.

Concerns were that facility staff did not reach out to the resident’s responsible party by not answering phone calls or text messages. Interviews conducted on 4/27/2021 starting at 12:18 pm, 3/2/22 at 4:30 pm, 3/3/22 at 9:08 am and 3/8/22 starting at 11:00 am revealed that resident’s responsible persons phone calls and/or text messages are being answered. Based on the information obtained during the course of the investigation the allegation is deemed unsubstantiated at this time.


Exit interview conducted. Today's reports and appeal rights were reviewed and emailed to the Administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022
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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