198603521-6-15-2022-28-AS-FFIS-CFFUS2-20220616154938

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603521
Report Date: 05/24/2022
Date Signed: 06/15/2022 11:49:44 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/19/2022 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20220519103342

FACILITY NAME:	A PEACEFUL HOME OF COVINA		FACILITY NUMBER:	198603521
ADMINISTRATOR:	BUGASTO, MYRNA G.		FACILITY TYPE:	740
ADDRESS:	16025 E BRIDGER ST.		TELEPHONE:	(626) 244-9999
CITY:	COVINA	STATE: CA	ZIP CODE:	91722
CAPACITY:	6	CENSUS: 2	DATE:	05/24/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Elizah Arganosa, staff and Donisio Cueto, staff		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility did not follow resident's care plan.
Resident developed gangrene while in care.
Resident did not receive medication as prescribed by a physician.

INVESTIGATION FINDINGS:

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***This report serves as an amendment and supersedes the original complaint investigation report created on 05/24/2022. The purpose of this amended Licensing report is to clarify findings. The findings remain unsubstantiated. ***

Licensing Program Analyst (LPA) Tao, conducted an initial unannounced complaint investigation for the allegations listed above on 05/24/22. LPA was allowed entry by Donisio Cueto, staff, then, met with staff, Elizah Arganosa. Licensee, Steven Dong, joined the visit via phone call. LPA explained the purpose of the visit to staff and Licensee.
Investigation consisted of the following: interviews of staff from Staff #1 (S1) through Staff #3 (S3); interviews of residents from Resident #1 (R1) through Resident#2 (R2); interview of resident#3's family member; and reviews of Resident#3’s record.
LPA obtained copies of the staff and resident rosters; and resident#3 files with relevant information.
The investigation revealed the following: (-Continued in LIC9099 C-)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2022

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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Control Number 28-AS-20220519103342

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: A PEACEFUL HOME OF COVINA	FACILITY NUMBER: 198603521
	VISIT DATE: 05/24/2022

NARRATIVE

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***This report serves as an amendment and supersedes the original complaint investigation report created on 05/24/2022. ***

In regard to allegation: “Facility did not follow resident's care plan," it was alleged that staff did not follow resident's care plan to take care of resident#3. Two (2) residents were interviewed. Two (2) out of two (2) residents could not corroborate the allegation which revealed that staff followed their care plan to provide care. LPA interviewed with staff from Staff#1 to Staff #3. They denied the allegation. Interviews revealed that staff followed residents' care plan. Review of residents' records revealed staff followed residents care plan to provide care.

In regard to allegation: "Resident developed gangrene while in care," it was alleged that resident#3 developed gangrene while residing at the facility. Two (2) out of two (2) residents could not corroborate the allegation. Interview with resident#3 family member stated there was a wound on resident's right toe and no medical document to confirm the wound was a gangrene. Interviews staff from Staff#1 to Staff #3, staff denied the allegation. Review of residents' records revealed no medical record stated resident#3 developed gangrene when residing at the facility. Interviews and record reviews did not reveal resident#3 developed gangrene while in care.

In regard to allegation: "Resident did not receive medication as prescribed by a physician," it is alleged that staff did not administer medication to resident#3 as physician prescribed. Two (2) out of two (2) residents could not corroborate the allegation. Interviews staff from Staff#1 to Staff #3, staff denied the allegation. Review of residents' records revealed staff administered medication as prescribed. Staff interview revealed that residents have right to accept or reject medication. Interviews and record reviews did not reveal staff failed to administer medication as physician prescribed to residents.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove
the alleged violations did or did not occur, therefore, the allegations are UNSUBSTANTIATED. No deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8.

An exit interview was conducted with staff, Elizah; a hard copy of the report was provided on 5/24/22. This amended Licensing report is emailed to Licensee / Administrator, Steven Dong for signature on 6/15/22.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2022

LIC9099 (FAS) - (06/04)

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