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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603521
Report Date: 11/05/2024
Date Signed: 11/05/2024 03:57:49 PM

Unsubstantiated


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
11/01/2024 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241101111849
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:
11/05/2024
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Elizah Arganosa, Assistant AdministratorTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff handle resident in care in a rough manner.
Staff do not ensure that resident's toileting needs are met while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation on the allegations listed above. LPA arrived unannounced and met with the Assistant Administrator, Elizah Arganosa. The purpose for the visit was explained.

LPA obtained copies of the staff and resident rosters. Interviews were held with 4 Staff and 5 Residents.

The investigation revealed the following:
Allegation – Staff handle resident in care in a rough manner. Staff interviewed stated they received training on properly transferring of residents. They stated they handle residents as gently as possible and have not seen other staff be rough with residents. LPA interviewed 5 residents and 4 out of 5 stated staff handle them carefully while assisting them during transfer and other activities. They have not seen staff being rough with others either.
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: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
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 2
Control Number 28-AS-20241101111849
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: 11/05/2024
NARRATIVE
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Allegation – Staff do not ensure that resident’s toileting needs are met while in care. Staff interviewed stated they check on resident with incontinence every 2 hours. If the diapers need to be changed, they will do so immediately. Staff stated residents have call buttons and will let them know as well if their diaper is soiled. Staff denied leaving residents to sit in soiled diapers during the day or night. 4 out of the 5 residents interviewed indicated that the staff checks on them and change their diapers if needed. They are not left sitting in a soiled diaper.

Although the allegations may have happened or are valid, there is 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 E. Arganosa. A copy of this report along with the appeal rights was provided.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2