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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603521
Report Date: 08/25/2023
Date Signed: 08/25/2023 04:20:44 PM

Substantiated


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
08/21/2023 and conducted by Evaluator Valeria Maldonado
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230821113631
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: 6DATE:
08/25/2023
UNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Elizah Arganosa- AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Residents in care have access to centrally store medications.
Staff are unable to communicate with residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced complaint visit at the facility for the purpose of investigating the above-mentioned allegations. LPA Maldonado met with Administrator Elizah Arganosa and explained the purpose for the visit.

During today's visit, LPA Maldonado obtained a copy of the resident and staff roster, conducted a tour of the physical plant with Staff# 2 (S2) and obtained the following documents for Residents# 1-6 (R1-R6): Facesheet, Physcian's Report, Needs and Services Plan, and Special Incident Reports (SIRs) for July-August 2023. LPA also reviewed staff files for proof of completed training regarding Resident Personal Rights, Medication Administration, Centrally Stored Medications, and Continence Training. Interviews were conducted with S1-S3, attempted interviews with R1-R5. A telephonic interview with R6 was attempted due to resident being out of the facility, however LPA was unsuccessful..
The investigation revealed the following:
(Report Continued on LIC9099-C...)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
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 7
Control Number 28-AS-20230821113631
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: 08/25/2023
NARRATIVE
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Regarding allegation: Residents in care have access to centrally store medications.
It is alleged that resident's creams and ointments are being left in resident rooms, accessible to them. At 8:30AM, during the tour of the physical plant, LPA observed resident medication baskets filled with medications, left on top of the kitchen counter, along with other food items, while R3 was walking around the facility. LPA asked S2 why the medication was left out. S2 responded that due to deep cleaning of the kitchen cabinets, the medication was taken out and would be put back once completed. Staff continued to leave the medication out and unattended while S3 passed by several times sweeping and mopping the home. Shortly after, S1 arrived at the facility and sat at the kitchen counter in front of medication while speaking with S2, and the medication was still not put back. During the tour of resident bedrooms, LPA did not observe any medications, special creams, and/or ointments left accessible in their rooms. Per staff training records, training on Centrally Stored Medications was successfully completed on January, February March and August of 2023. Per interviews conducted with staff, (2) of (3) staff state that deep cleaning of the cabinets happens every other day and medications are usually left out that way. This allegation is Substantiated.

Regarding allegation: Staff are unable to communicate with residents in care.
It is alleged that residents are having trouble with speaking to care staff due to a language barrier and not understanding English well, causing issues to arise. During the interview conducted with S3, LPA Maldonado had to rephrase the questions being asked several times due to S2 speaking little English and not fully understanding the questions. During interviews conducted with staff, (3) of (3) denied the allegation and stated they had no issues communicating with residents due to language barriers. Per interviews conducted with residents, R2 corroborated the allegation, stating that it is hard to communicate with S2 because S2 does not understand much English. R2 stated that many times, R2 has to ask the same questions for S2 to understand what R2 is asking- however R2's needs are still being met. This allegation is Substantiated.

Based on LPA's observations and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is SUBSTANTIATED.

Per California Code of Regulations, Title 22, deficiencies were observed and will be cited on the LIC9099-D.

An exit interview was conducted with Administrator Elizah Arganosa and a copy of the report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 28-AS-20230821113631
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
08/26/2023
Section Cited
CCR
87465(2)
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87465 Incidental Medical and Dental Care
(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 of the...medication.
This requirement was not met as evidenced by:
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Staff put medications away in their centrally stored cabinet under lock and key during the visit.
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Based on observations and interviews, the licensee failed to maintain centrally stored medication inaccessible to residents in care, as LPA observed the medications on top of the kitchen counter, which poses a immediate Health, Safety, or Personal Rights risk to persons in care.
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Deficiency Dismissed
Type B
09/01/2023
Section Cited
CCR
87468.2
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(14)To reasonable accommodation of their individual... preferences in all aspects of life in the facility...
This requirement was not met as evidenced by:
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Licensee will submit a written plan on how staff will continue to provide services and meet resident needs despite language barriers, to LPA via email by POC due date.
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Based on obsevation and interview, the licensee failed to have direct care staff who can speak and understand the same language as other residents who reside in the facility, which can pose a potential Health, Saftey, or Personal Rights risk to persons 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: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
08/21/2023 and conducted by Evaluator Valeria Maldonado
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230821113631

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: 6DATE:
08/25/2023
UNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Elizah Arganosa- AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Resident sustained pressure injuries while in care due to lack of care and supervision.
Staff do not ensure facility is kept clean.
Staff do not provide proper incontinence care to residents in care.
Residents are not provided proper food service.
Residents are not provided proper medication assistance.
Objects that pose a risk to residents are accessible to residents in care.
Staff do not ensure resident's personal items are safeguarded.
Staff are not meeting residents need by abandoning their shift.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced complaint visit at the facility for the purpose of investigating the above-mentioned allegations. LPA Maldonado met with Administrator Elizah Arganosa and explained the purpose for the visit.

During today's visit, LPA Maldonado obtained a copy of the resident and staff roster, conducted a tour of the physical plant with Staff# 2 (S2) and obtained the following documents for Residents# 1-6 (R1-R6): Facesheet, Physcian's Report, Needs and Services Plan, and Special Incident Reports (SIRs) for July-August 2023. LPA obtained proof of completed training for staff specifically for Resident Personal Rights, Medication Administration, Centrally Stored Medications, and Continence Training. A copy of R3's Hospice Care Plan and hospice notes were also obtained. LPA conducted interviews with S1-S3, attempted interviews with R1-R5, and telephonic interview with R6 was attempted due to resident being out of the facility, however LPA was unsuccessful. LPA also reviewed resident medications and the Medication Administration Records (MARs). (Report Continued on LIC9099-C...)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
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 7
Control Number 28-AS-20230821113631
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: 08/25/2023
NARRATIVE
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The investigation revealed the following:
Regarding allegation: Resident sustained pressure injuries while in care due to lack of care and supervision.
It is alleged that R3 was taken to the hospital due to bed sores. Per review of incident report dated 7/25/23, 911 was called on 7/20/23 due to R3 passing out, as R3 was eating less and drinking less fluids. At the time of the incident, R3 was being provided physical therapy and regular nurse checks by Home Health. Per interview with R1, R3 returned back to the facility on Hospice due to R3's declining health, with admission date of 8/03/23 and hospice care plan requires R3 to be repositioned every two hours. Per interviews conducted with staff, (3) of (3) staff stated that all bedridden residents are repositioned every (2) hours. Per hospice notes, on 8/11/23, 8/15/23 and 8/21/23, R3 did not receive any wound care. On 8/25/23, R3 was treated for four (4) stage 2 ulcers on the sacral/buttocks area. LPA attempted to interview R3, but was unable to due to R3's cognitive impairment. This allegation is Unsubstantiated.
Regarding allegation: Staff do not ensure facility is kept clean.
It is alleged that the facility is unclean and staff do not clean resident rooms regularly. Per interviews conducted with R1-R5, (3) of (5) residents denied the allegation and stated that staff clean daily by sweeping, moping, dusting, and washing resident personal items. Upon arrival, LPA observed S2 sweeping and moping the common areas and resident rooms, and S3 was cleaning the kitchen cabinets and dining room area. LPA inspected resident rooms and resident bathroom. They appeared to be clean, sanitary, organized, and free of hazards. (3) of (3) staff stated the facility is cleaned regularly on a daily basis and deep cleaning of the kitchen is done every other day. This allegation is unsubstantiated.
Regarding allegation: Staff do not provide proper incontinence care to residents in care.
It is alleged that R1 was neglected by staff and acquired a diaper rash while in care. Per staff interviews, (3) of (3) staff stated that residents who require incontinence care are checked on and changed every 2 hours or more frequently, if needed. LPA was unable to interview R1 due to R1 being in the hospital. LPA attempted to interview R1 telephonically at the hospital, however, LPA was informed by hospital staff that R1 is no longer there. (3) of (5) resident's interviewed denied the allegation and stated that staff assist them with changing and frequently check them for changing needs. This allegation is unsubstantiated.
Regarding allegation: Residents are not provided proper food service.
It is alleged that the facility is not serving residents healthy meals. During today's visit, LPA observed the facility food supplies and obtained a copy of the facility menu and resident's dietary restrictions. LPA observed a sufficient amount of food that meets Title 22 Regulation requirements of 2-day perishables and 7-day non-perishables for the amount of residents in care. (Report Continued on LIC9099-C...)
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 28-AS-20230821113631
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: 08/25/2023
NARRATIVE
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There was a variety of nutritious foods available such as fresh fruits, vegetables, proteins, milk, and juices. The menu posted on the refrigerator reflected a variety of nutritious meals to be served and the resident's dietary restrictions was posted next to it to remind staff of resident's requirements/needs during meals. (3) of (5) residents interviewed denied the allegation and stated that they have no complaints about the food service. They are provided options when they ask and are given 3 meals a day with snacks in between. (3) of (3) staff interviewed stated they follow resident's special diets, provide them with 3 meals per day, give them options if they desire something different, and provide snacks between meals. This allegation is unsubstantiated.
Regarding allegation: Residents are not provided proper medication assistance.
It is alleged that staff are making medication errors. LPA reviewed resident medications and the MARs. It was determined that (6) of (6) residents medications are being administered as described and documented properly. (3) of (5) residents interviewed stated that staff assist them with administering their medications. (3) of (3) staff interviewed stated medications are given to residents daily as prescribed and denied any medication errors occurring. Per staff training certification, it was discovered that all staff have received proper medication administration training and resident's personal rights on medication refusal/acceptance. This allegation is Unsubstantiated.
Regarding allegation: Objects that pose a risk to residents are accessible to residents in care.
It is alleged that residents that there are harmful objects in residents rooms with dementia and psychosis. LPA Maldonado inspected resident rooms and did not observe any hazardous items accessible to residents in care. (3) of (5) residents denied the allegation and stated that all hazardous objects/materials are locked in different cabinets in the facility. (3) of (3) staff stated that all hazardous/toxic items including medications and ointments are kept locked and inaccessible to residents in care. LPA observed all sharps, medications, special ointments, and cleaning supplies/toxins to be stored in a locked drawer in the kitchen, in the garage which remains locked, and in a locked cabinet in the hallway- all inaccessible to residents in care. This allegation is unsubstantiated.
Regarding allegation: Staff do not ensure resident's personal items are safeguarded.
It is alleged that care staff are asking for things/money from residents. (3) of (5) residents denied the allegation and stated that staff are very professional and caring. R3 stated to have offered S2 a bracelet one time as a thank-you, however S2 did not accept it. (3) of (3) staff denied the allegation and stated staff are trained to not accept anything from residents for the care being provided. This allegation is Unsubstantiated.

(Report continued on LIC9099-C...)
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 28-AS-20230821113631
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: 08/25/2023
NARRATIVE
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Regarding allegation: Staff are not meeting residents need by abandoning their shift.
It is alleged that care staff are abandoning their posts. Per interviews conducted (3) of (3) staff denied the allegation and stated that residents are never left unsupervised and their care needs are being met. Per S1, there are no issues with staffing, nor have there been at any time. Per the staff roster, there are currently (7) staff working at the facility, some on-call. Per S1, if any staff call off, they can call their on-call staff to cover shifts if needed. (3) of (5) residents interviewed, the allegation was denied and staff are always present at the facility to provided assistance and supervision. This allegation is Unsubstantiated.

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.

Per California Code of Regulations, Title 22, no deficiencies were observed or cited.

An exit interview was conducted with Assistant Administrator Elizah Arganosa, and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7