Cathy's Cottage Palms

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Raquel Hernandez made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with staff and was granted entry to the facility. Licensed capacity is (6) current census (5). LPA was accompanied by Assistant Administrator Elizabeth Gail to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. Hot water temperature tested within regulation at 108 degress F. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated office for resident/staff files. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a variety of food available for residents. Dishes, cups, and utensils were also stored properly. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. Record Review: LPA reviewed (3) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA reviewed (3) resident medications. No issues were observed. LPA also reviewed (3) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings. No issues were observed. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) was discussed and provided to Assistant Administrator Elizabeth Gail.the state’s words, verbatim · CDSS document, Jul 17, 2026

Allegation investigated: Questionable death due to staff neglect. Staff failed to respond to resident's call light. Facility staff did not provide resident's records to responsible person.

Licensing Program Analyst (LPA) Raquel Hernandez conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Assistant Administrator Elizabeth Gail and explained the purpose of the visit. The investigation conducted by Department staff consisted of staff interviews, resident interviews and document review. Allegation: Questionable death due to staff neglect The investigation did not provide sufficient evidence to corroborate the allegation of Questionable Death due to staff neglect. Resident 1 (R1) was admitted to Cathy’s Cottage Palms on December 3, 2024, after a history of falling at home. R1 was diagnosed with dementia and had an unsteady gait. R1 passed away on December 14, 2024, when R1 was found unresponsive by the caregiver with head wedged between the mattress and the bed rail. Unsubstantiated The coroner’s report indicated, Cause of death, as Positional Asphyxia with other significant conditions contributing to the death. Injury/Mode was categorized as accident. There were no other concerning or suspicious factors that contributed to R1’s death. Allegation: Staff failed to respond to R1’s call light. On December 14, 2024, R1 was found unresponsive by Staff 1 (S1) with head wedged between the mattress and the bed rail. On the day of the incident, S1 indicated she checked on R1 every two hours. At 0100 hours, S1 checked on R1 and R1 was observed to be asleep. At 0200 hours, S1 heard R1’s alarm sound and responded to R1’s room. S1 observed R1’s blankets were off and R1 was tossing and turning in bed. S1 put the blankets back on and left the room. Between 0330 and 0400 hours, R1’s alarm sounded again, and S1 responded to R1’s room within two minutes. S1 was assisting Resident 2 (R2) with a bowel movement. Once S1 responded, S1 found R1 to be unresponsive, kneeling on the floor with his head wedged between the mattress and the bedrail. There was insufficient evidence to corroborate that staff failed to respond to R1’s bed alarm in a timely manner. Allegation: Facility staff did not provide resident's records to responsible person LPA observed no formal request of resident records that are located at the facility. Administrator indicated R1’s records are provided to responsible party when requested, however, request of hospice documentation that is not located in resident's file, is directed to hospice agency. Based on the evidence, there is insufficient evidence to corroborate the three allegations listed above. Therefore, the findings are UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted where this report (LIC9099) was discussed, and a copy was provided to Assistant Administrator Elizabeth Gail.the state’s words, verbatim · CDSS document, Jun 30, 2025 · control 56-AS-20250205133023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Javier Prieto made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. Administrator Julie Birkinbine welcomed LPA and was granted entry to the facility. The facility is a four (5) bedroom, two and a quarter (2 1/4), bathroom home and, with a kitchen/dining area, and living room. Licensed capacity is six (6) current census four (4). LPA was accompanied by Julie Birkinbine to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. All sharps are locked. There was a designated office for client/staff files. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care. Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. Record Review: LPA reviewed four (4) client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed one (1) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. This report was signed by LPA Prieto and Administrator Birkinbine and this report was left with the facility.the state’s words, verbatim · CDSS document, Jul 22, 2024