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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603521
Report Date: 01/12/2023
Date Signed: 01/12/2023 01:39:43 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
01/03/2023 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230103145542
FACILITY NAME:A PEACEFUL HOME OF COVINAFACILITY NUMBER:
198603521
ADMINISTRATOR:BUGASTO, MYRNA G.FACILITY TYPE:
740
ADDRESS:16025 E BRIDGER ST.TELEPHONE:
(626) 244-9999
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY:6CENSUS: 4DATE:
01/12/2023
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Thang Duong, AdministratorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff mismanaged resident's medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted an unannounced complaint investigation regarding the above allegation. LPA met with Administrator, Thang Duong, and explained the reason for the visit.

The investigation consisted of the following:
LPA obtained copies of the Staff & Resident rosters. LPA reviewed files and medications for 4residents. Interviews were conducted with the Administrator, 3 Staff, and 3 Residents.

The investigation revealed the following:
Regarding allegation, Staff mismanaged resident’s medication. It is alleged that the labels on the medications did not match the written instructions on the Medication Administration Record (MAR) log or had been altered, extra medication are given to the residents, and/or a resident is storing medication in the room.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
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 5
Control Number 28-AS-20230103145542
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: A PEACEFUL HOME OF COVINA
FACILITY NUMBER: 198603521
VISIT DATE: 01/12/2023
NARRATIVE
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During the visit today, LPA reviewed medication for 4 residents. There were discrepancies found on all 4 residents’ medications. LPA observed that 3 of the medications listed on Resident #1’s MAR log were missing. Residents #2, #3, and #4 all had an extra bottle of medication that was not listed on the MAR log. Staff could not provide the physician’s order for the extra medications found. Staff stated that residents are medication compliant. LPA interviewed 3 residents and all 3 stated they take their medications daily. In addition, LPA observed a clear container with 3-4 pills on a chair inside Resident #1's room at approximately 11am. When LPA inquired about the container of pills, staff replied the resident wanted to take the morning pills later. Resident #1's physician's report indicated that resident is not able to store own medication.

Based on LPA observation, interviews conducted, and record review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D.



An exit interview was conducted. The Plan of Corrections were reviewed and developed with Staff Elizah Arganosa. A copy of this report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20230103145542
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: A PEACEFUL HOME OF COVINA
FACILITY NUMBER: 198603521
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/13/2023
Section Cited
CCR
87465(h)(4)
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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws....

This requirement is not met as evidenced by:
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The licensee shall review medications for all residents and ensure that all medications ordered by the physician are maintained at the facility and written on the MAR log. The POC is due by 1/13/23.
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Based on record review, all 4 residents' medication either had medications not written on the MAR log or the medication was not found which poses an immediate health and safety risk to residents in care.
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Type A
01/13/2023
Section Cited
CCR
87465(h)(2)
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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision...
This requirement is not met as evidenced by:
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The licensee shall ensure that no medications are kept in the residents' rooms and have an in-service training with staff to go over this subject matter. This POC is due by 1/13/23.
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Based on observation, Resident #1 had a clear container with 3-4 pills in the room which poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
01/03/2023 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230103145542

FACILITY NAME:A PEACEFUL HOME OF COVINAFACILITY NUMBER:
198603521
ADMINISTRATOR:BUGASTO, MYRNA G.FACILITY TYPE:
740
ADDRESS:16025 E BRIDGER ST.TELEPHONE:
(626) 244-9999
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY:6CENSUS: 4DATE:
01/12/2023
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Thang Duong, AdministratorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Resident is not being fed enough.
Staff failed to treat resident with dignity and respect.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted an unannounced complaint investigation regarding the above allegations. LPA met with Administrator, Thang Duong, and explained the reason for the visit.

The investigation consisted of the following:
LPA obtained copies of the Staff & Resident rosters. LPA reviewed files and medications for 4residents. Interviews were conducted with the Administrator, 3 Staff, and 3 Residents.

The investigation revealed the following:
Regarding allegation, Resident is not being fed enough. It is alleged that one of the residents was fed only 2 times a day. The Administrator and staff interviewed denied feeding a resident twice a day. They stated residents are given 3 meals daily; breakfast, lunch, and dinner as well as snacks. Staff stated that residents are given adequate portion of food, while being aware of their weights and dietary intake.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20230103145542
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: A PEACEFUL HOME OF COVINA
FACILITY NUMBER: 198603521
VISIT DATE: 01/12/2023
NARRATIVE
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The residents interviewed stated they get 3 meals a day and snacks. Some stated they offer snacks but sometimes decline it. They have no concerns in regard to not getting fed enough. LPA observed sufficient amount of food for 4 residents.

Regarding allegation, Staff failed to treat resident with dignity and respect. Administrator and staff stated they treat all residents with dignity and respect. The Administrator stated if he observes or hears a staff member mistreating a resident, he will terminate the staff immediately. Staff denied making inappropriate comments toward a resident or disrespecting them. They stated they receive training on personal rights and are aware of how they interact with residents. 2 out of the 3 residents interviewed feel that the staff are always helpful and respectful.

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

An exit interview was conducted with Staff Elizah Arganosa and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5