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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606347
Report Date: 04/03/2025
Date Signed: 04/03/2025 12:04:01 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
01/21/2025 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250121144952
FACILITY NAME:COGSWELL GARDEN HOMEFACILITY NUMBER:
197606347
ADMINISTRATOR:LILIAN C. SALMORINFACILITY TYPE:
740
ADDRESS:5405 N. COGSWELL ROADTELEPHONE:
(626) 444-3523
CITY:EL MONTESTATE: CAZIP CODE:
91732
CAPACITY:15CENSUS: 7DATE:
04/03/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Lilian SalmorinTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Resident sustained multiple unexplained fractures
Staff did not seek timely medical attention for resident
Staff did not notify resident's authorized representative of resident's fractures
Staff did not follow resident(s) diet as prescribed by a physician
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Staff S1 and explained the reason for the visit.
The purpose of the visit is to deliver findings from the original complaint dated 01/21/2025.
Shortly thereafter Administrator Lilian Salmorin arrived.
The initial visit was a Health and Safety Check conducted on 01/21/2025 and included the following:
LPA reviewed Resident R1's file and facility to submit Emergency Face Sheet, Admission Agreement, Individual Program Plan (IPP), Special Incident Reports (SIR"s), Physician's Report, Hospital Documentation, and Nursing Care Plan,
LPA conducted a tour of the facility inside and out with Staff S1 and observed clients in the facility at the time of the visit. Facility had sufficient 2 day supply of perishables and 7 days supply of non- perishables and the water temperature measured between 105 F. and 120 F.both meeting Title 22 Regulations.
LPA observed the clients to identify any signs of neglect, abuse or other immediate Health and Safety
threats. LPA did not observe any immediate Health & Safety concerns during the visit.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
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 4
Control Number 28-AS-20250121144952
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: COGSWELL GARDEN HOME
FACILITY NUMBER: 197606347
VISIT DATE: 04/03/2025
NARRATIVE
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At today's visit interview was conducted with Administrator Lilian Salmorin and Staff S1.
Investigation was conducted by the Investigations Branch (IB) and completed 03/19/2025 for allegations
Resident sustained multiple unexplained fractures and Staff did not seek timely medical attention for resident.
Investigation consisted of interviews with facility staff, residents, review of medical documentation and Special Incident Reports (SIR's) from San Gabriel Pomona Regional Center and from Cogswell Garden Home.
Photograph of Resident R1 taken on 11/08/2023 was observed and file was reviewed.
In regards to the allegation Resident sustained multiple unexplained fractures based on interviews conducted and information gathered Investigation was completed by Investigations Branch (IB) Investigator Christine Ferris on 03/19/2025 it was revealed that Staff denied Resident R1 had any falls or sustained any injuries at the facility. Mainstream Day Program Administrator reported Resident R1 has fallen while attending day program but did not sustain any injuries. Per family member of Resident R1, Resident R1 has not disclosed any falls to her and was recently diagnosed with osteopenia and then osteoporosis. Per San Gabriel/Pomona Regional Center Case Manager and reports provided, Resident R1 sustained a rib fracture and foot fracture prior to residing at the facility and the facility has been communicative regarding any falls or injuries, yet there have been no reports of Resident R1 falling or sustaining any injuries. Resident R1 was unable to provide a meaningful statement, and clients did not report any concerns. Per Kaiser Permanente Baldwin Park medical records, the fractures found were age indeterminable and suspected as being old. There was no evidence to indicate Resident R1 sustained his injuries at the facility, therefore, the allegation is unsubstantiated.

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

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20250121144952
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: COGSWELL GARDEN HOME
FACILITY NUMBER: 197606347
VISIT DATE: 04/03/2025
NARRATIVE
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In regards to the allegation Staff did not seek timely medical attention for resident, Investigation was completed by Investigations Branch (IB) Investigator Christine Ferris on 03/19/2025 it was revealed that
the investigation did not provide sufficient evidence to substantiate neglect/lack of care in not seeking timely medical attention. Staff denied Resident R1 had any falls or sustained any injuries at the facility, thus, no medical attention was needed. Therefore, the allegation is unsubstantiated.
Day Program interview with the Administrator stated that on 01/08/25 Resident R1 was pushed off his chair and has known Resident R1 40 years and he has not complained about falling at home or being at home.
Residents interviewed had not witnessed any falls at the home.

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

In regards to the allegation Staff did not notify Resident R1's authorized representative of resident's fractures it was determined by the Investigator in IB Investigation that residents, and staff had never observed a fall at the home and Day Program Administrator stated resident had fallen when pushed off his chair.
Interview with Administrator at Cogswell who stated that Resident R1 had never fallen at the facility so therefore there was not anything to report to the authorized representative.
Interview with Staff S1 who stated they did not report anything to Resident R1's authorized representative because there was nothing to report. Stated they have in the past always notified the authorized representative.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove
alleged violation did or did not occur, therefore the above allegation is Unsubstantiated.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20250121144952
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: COGSWELL GARDEN HOME
FACILITY NUMBER: 197606347
VISIT DATE: 04/03/2025
NARRATIVE
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In regards to the allegation Staff did not follow residents diet as prescribed by a physician, based on interviews conducted and information gathered it was revealed by Administrator Lilian Salmorin that every 3 months Resident R1 goes to the PKU specialist at UCLA.
Documentation from Kaiser UCLA was observed dated 03/03/2025 which showed Resident R1's blood work related to PKU.
Dietician at UCLA recommended juice formula and no medication for PKU.
Administrator stated there is a diet just for him and it is posted on the refrigerator and the LPA observed it at today's visit.
File for Resident R1 revealed documents for meat and meat substitutes, low protein, low-fat milk, fruits and berries.
Interview with Staff S1 who stated that the PKU diet is followed for Resident R1.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove
alleged violation did or did not occur, therefore the above allegation is Unsubstantiated.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4