198603521-8-29-2023-28-AS-RORN-CW9NJB-20231003103004

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603521
Report Date: 08/29/2023
Date Signed: 08/29/2023 02:24:54 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, 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
08/22/2023 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20230822154400

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: 5	DATE:	08/29/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Thang Steven Duong, Licensee		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff is not meeting residents’ diabetic needs.
Staff is not meeting residents’ hygiene needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tao conducted unannounced complaint investigation for the allegations listed above today. During today’s visit, LPA met with Licensee, Thang Duong. LPA explained the purpose of today's visit regarding the above-mentioned allegations.

Investigation consisted of the following: interviews of staff from staff #1 (S1) through staff #4 (S4); interviews of residents of resident#3 (R3), resident#4 (R4) and resident#6 (R6) and attempted to interview resident #1 (R1), resident #2 (R2) and resident #5 (R5), interviewed visitor#1 (V1); reviewed resident#1’s record reviews, and facility tour was conducted.

LPA obtained copies of staff/resident rosters; and resident files for resident #1 (R1) with relevant information.

(-continued in LIC 9099 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: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

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-20230822154400

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: 08/29/2023

NARRATIVE

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The investigation revealed that:

In regard of the allegation, “staff is not meeting residents’ diabetic needs,” it was alleged that facility did not provide residents with proper dietary to meet their special dietary needs. The investigation revealed the following: interviewed with residents of R3, R4 and R6, residents interviews revealed that staff provided adequate diet for their dietary needs. LPA attempted to interview R1, R2 and R5, all attempts failed. Per staff interviews, all four (4) staff denied the allegation. LPA interviewed visitor #1 (V1), who was resident#1 (R1)’s family member and could not corroborate with the allegation. File review revealed residents’ special dietary needs was written on a sheet and posted on the refrigerator in the kitchen. Staff would follow instructions on that sheet when preparing residents’ meals. Thus, staff meets residents’ diabetic needs.

In regard of the allegation, “staff is not meeting residents’ hygiene needs,” it was alleged that staff did not bath residents to meet their hygiene needs. The investigation revealed the following: interviewed with residents of R3, R4 and R6, residents interviews revealed that staff bathe residents at least twice a week. LPA attempted to interview R1, R2 and R5, all attempts failed. Per staff interviews, all four (4) staff denied the allegation. LPA interviewed visitor #1 (V1), who was resident#1 (R1)’s family member, and could not corroborate with the allegation. LPA toured the facility and observed residents looked clean. LPA was not aware of foul smell at the facility. Thus, staff meets residents’ hygiene needs.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is UNSUBSTANTIATED.

No deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8.

An exit interview was conducted with Licensee/ Administrator, Steven. A hard copy of this report was provided

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC9099 (FAS) - (06/04)

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