306006260-8-25-2026-22-AS-AORZ-DXGTE9-20260831143933

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006260
Report Date: 08/25/2026
Date Signed: 08/25/2026 04:42:43 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/20/2026 and conducted by Evaluator Andrea Mendivil

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20260320171458

FACILITY NAME:	IRVINE COTTAGE #1		FACILITY NUMBER:	306006260
ADMINISTRATOR:	ARNETT, KIMBERLY		FACILITY TYPE:	740
ADDRESS:	1 LONGSTREET		TELEPHONE:	(949) 533-5938
CITY:	IRVINE	STATE: CA	ZIP CODE:	92620
CAPACITY:	6	CENSUS: 6	DATE:	08/25/2026
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Kimberly Arnett - Executive Administrator		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Lack of supervision resulting in residents sustaining injuries.
Facility did not provide planned activities.
Residents were not accorded a safe environment.
Resident's representative was not provided access to the resident's record.
Resident's representative was not informed about the resident's care.
Facility statff made a misleading statement regarding resident's care.
Staff did not ensure residents were fed resulting in weight loss

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility and explained the reason for the visit.

The Department received a complaint on March 20, 2026. The Department obtained copies of pertinent documents such as resident's physician report, admission agreement, and apprasials. LPA interviewed staff and residents. Regarding the allegations Lack of supervision resulting in residents sustaining injuries.
Facility did not provide planned activities, Residents were not accorded a safe environment, Resident's representative was not provided access to the resident's record, Resident's representative was not informed about the resident's care, Facility staff made a misleading statement regarding resident's care, Staff did not ensure residents were fed resulting in weight loss, the investigation revealed the following :

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2026

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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Control Number 22-AS-20260320171458

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: IRVINE COTTAGE #1	FACILITY NUMBER: 306006260
	VISIT DATE: 08/25/2026

NARRATIVE

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It was reported to the Department that Resident 1 (R1) was injured by Resident 2 (R2) during the night/early morning hours of February 1, 2026. It was reported that staff informed Administrator Kimberly Arnett that R1 had a swollen right hand on February 1, 2026 around 9AM. Administrator stated they called R1’s responsible party to notify them of the issue. R1’s responsible party took R1 to the emergency room, during the ER visit R1’s responsible party called Administrator R1’s responsible party advised the Administrator R1 disclosed a female nurse came into their room and twisted their hand back and the female nurse then placed her hand over R1’s mouth. Administrator Kimberly reported that they reviewed internal camera footage and it showed staff placing R1 in their room around 11:03 pm. During review of the footage Administrator stated the video showed R2 going into R1’s room around 3:40am and leaving approximately 2 minutes later.
Administrator Kimberly stated they called OC Sheriff’s non emergent line but was told to call back when R1 returned to the facility. R1 returned on the same day of February 1, 2026 with a splint for immobilization. It was stated then staff called OC Sheriff’s non emergent line but was transferred to Irvine Police Department. Officer M. Krouse (Badge # 655) arrived at the facility. It was reported by staff R1 and R2 were interviewed by Officer M. Krouse and staff was informed no other follow up needed for the incident. It was reported that R2 stated they were sleep walking. LPA could not confirm the events with R1 as they were not oriented to time and space during the interview process. LPA could not confirm the events with R2 as they were not available for interview.
It was alleged lack of care and supervision resulted in residents sustaining injuries. Per review of R1 and R2’s physician reports neither resident had wandering issues or required awake staff. Per interviews with 2 out of 2 staff indicated no other resident required awake night staff. Interviews with 2 out of 2 staff stated this was R2’s first incident of sleep walking or issues with aggressive behaviors.
It was alleged that residents were not accorded a safe environment. Per review of both R1 and R2’s pre-placement appraisals neither needed awake staff at night for wandering behaviors. Per review of incident reports submitted by the facility this is R2’s first incident of any behaviors with other residents. After the incident on February 1, 2026, R2 was re-evaluated and moved to a new facility. Interviews with 3 out of 6 residents reported they do not have concerns about their safety at the facility.
It was alleged that resident's representative was not provided access to the resident's record. Administrator Kimberly reported that R1’s medical records are stored by their own health insurance and R1’s family would have to supply those reports to the facility such as after summary visits, medication list, and physician’s reports. Administrator stated there is no form that the family does not have access to unless it is an internal document meant for staff only.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2026

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20260320171458

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: IRVINE COTTAGE #1	FACILITY NUMBER: 306006260
	VISIT DATE: 08/25/2026

NARRATIVE

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It was alleged that residents representative was not informed about the resident’s care. Per interviews with facility, 2 out of 2 staff deny that R1’s responsible party was not informed of R1’s care as R1’s responsible party came to the facility as a result of the facility’s reporting.
It was alleged that staff made a misleading statement regarding resident’s care. Per interviews R1’s responsible party was notified that R1 had a swollen hand, no reason for the injury was provided until R1’s responsible party advised Administrator Kimberly about the “female nurse” that was later determined to be R2.
It was alleged that staff did not ensure residents were fed resulting in weight loss. Per review of facility meal photos sent in November and December 2025, the facility documented R1’s meal consumption. Per review of R1’s physician’s report R1 is able to feed themselves. During today’s visit LPA observed residents eating a meal of chicken, mashed potatoes, green salad, and chopped fruit.

It was alleged that the facility does not provide planned activities. Interviews with 3 out of 6 residents interviewed stated they do not wish to participate in activities. The remaining 3 residents were not oriented to time or space or were not available for interviews. Administrator Kimberly stated activities are offered such as working out, walks outside to the park, coloring and arts/crafts.

Therefore based on the preponderance of evidence through records reviewed ,interviews and observations the allegations Lack of supervision resulting in residents sustaining injuries, Facility did not provide planned activities, Residents were not accorded a safe environment, Resident's representative was not provided access to the resident's record, Resident's representative was not informed about the resident's care, Facility staff made a misleading statement regarding resident's care, Staff did not ensure residents were fed resulting in weight loss meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred.
No deficiencies cited.
An exit interview was conducted and a copy of this report was provided.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2026

LIC9099 (FAS) - (06/04)

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