565850074-1-23-2024-29-AS-KBUY-CZYSWU-20240130131456

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850074
Report Date: 01/23/2024
Date Signed: 01/23/2024 11:45:01 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
05/05/2022 and conducted by Evaluator Erika Miller

COMPLAINT CONTROL NUMBER: 29-AS-20220505160911

FACILITY NAME:	COTTAGE INN		FACILITY NUMBER:	565850074
ADMINISTRATOR:	CINTHIA MEZA		FACILITY TYPE:	740
ADDRESS:	191 WAYVIEW CT		TELEPHONE:	(805) 650-7497
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY:	6	CENSUS: 5	DATE:	01/23/2024
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Judith Gonzalez, Lead Staff		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff left resident in soiled diaper for extended period of time
Resident is dehydrated
Staff are not responding to residents call button

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Erika Miller (Miller) and Jenny Olson (Olson) conducted an unannounced subsequent complaint visit to issue final findings on the allegations above. During the investigation, LPA, Angel Ascencio, toured the facility and interviewed Administrator, staff, and residents on May 10, 2022 from 11:45am to 4:30pm. LPAs Miller and Olson also toured the facility on January 23, 2024 and interviewed residents and staff from 10:52 a.m. to 11:10 a.m. LPAs also obtained and reviewed relevant documents. LPAs met with Lead Staff, and explained the purpose of the visit.

On the allegation: Staff left resident in soiled diaper for extended period of time.
On 5/28/22, a witness visited the facility and observed Resident 1 (R1) had dried feces on them, a rash, a Urinary Tract Infection (UTI), and chronic C-diff. R1’s physician’s report dated 4/22/2022 indicated they had bowel and bladder impairment, and needed assistance with toileting. R1’s previous stroke rendered them incontinent at times, and R1 also required incontinence care. LPAs interviewed residents, who indicated sometimes staff take a while to respond to their call buttons. Continued on 9099-C (pg 2)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

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 3

Control Number 29-AS-20220505160911

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: COTTAGE INN	FACILITY NUMBER: 565850074
	VISIT DATE: 01/23/2024

NARRATIVE

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One resident indicated sometimes they have to wait “a while” for staff to change them. Administrator stated R1 had a redness on their bottom but not an open sore. On 5/3/2022, a witness had a scheduled visit to the facility, and R1 was in the shower when they arrived and observed R1 had diaper cream on their buttocks after the shower. Administrator stated staff check on residents about every 45 minutes, but it could be 1-2 hours when staff are busy. Administrator stated they change residents at breakfast, lunch, and dinner, and “what’s needed in between, or as needed.” Staff interviewed stated they changed residents when needed, or when residents indicate they are soiled. Based on the information obtained, the allegation is deemed Unsubstantiated at this time.

On the allegation: Resident is dehydrated.
On 5/4/2022, a witness visited R1 and observed R1 to be dehydrated in their opinion. The witness rang R1’s bell to get water for R1, and staff did not respond to the bell. Per the witness, they believe the staff could not hear the resident’s bell. Staff interviewed indicated one of the residents drinks a lot of water, and therefore uses the restroom frequently. Staff also stated another resident had UTI symptoms and needed to drink a lot more, so they encourage the resident to drink or give them more liquid during meals. Staff stated they also have snacks between meals, which include smoothies, milk or other liquids. Based on the information obtained, the allegation is deemed Unsubstantiated at this time.

On the allegation: Staff are not responding to residents call button.
According to the witness, R1 indicated staff do not respond to their bell when they ring it for assistance. On 5/4/2022, a witness visited R1 and observed R1 to be dehydrated in their opinion. The witness rang R1’s bell to get water for R1, and staff did not respond to the bell. Per the witness, they believe the staff could not hear the resident’s bell. R1 was non-ambulatory, and was unable to walk without assistance, including a walker and wheelchair. R1 required help transferring in and out of bed. During the visit on 5/10/2022, LPA observed a resident use their call bell for assistance at 3:26 PM. The resident rang the bell, and staff left to assist the resident at 3:27 PM. LPAs interviewed residents about their call bells and how long it takes staff to respond. One resident indicated they did not know how to call for help, but indicated it takes a while for staff to come assist. Other residents indicated when they ring their bell, sometimes it takes a while for staff to respond. On 5/10/22 Administrator stated they use hand bells as a call system, and staff respond to residents when they ring the bell.

Continued on 9099 C- (Page 3)

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20220505160911

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: COTTAGE INN	FACILITY NUMBER: 565850074
	VISIT DATE: 01/23/2024

NARRATIVE

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On 1/23/24 Staff stated that three out of five residents have an electronic call button. One resident’s spouse prefers that they have a hand bell. Staff stated that another resident does not know how to use an electronic bell and uses the hand bell. Staff stated R1 had a call alert button in their room that they used to summon staff. Staff interviewed indicated they respond to resident’s needs. Based on the information obtained, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted, copy of report issued.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

LIC9099 (FAS) - (06/04)

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