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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606347
Report Date: 06/16/2021
Date Signed: 06/16/2021 02:55:12 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
06/14/2021 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210614162433
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: 10DATE:
06/16/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Gilbert Marasigan House ManagerTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Medication not administered as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Glenn Trueman, made a visit to Cogswell Garden Home. The purpose of today's visit is to investigate the allegation above.
On today's visit LPA met with Gilbert Marasigan House Manager. LPA received a report from the SG/Pomona Regional Center dated June 10, 2021. The report states that on May 24, 2021 Resident #1 was not dispensed morning medication Amlodipine Besylate 5 mg. 1 tablet to be given at 7 AM. It was observed at 1:50 PM still in the bubble pack.
Interview conducted with Gilbert Marasigan House Manager at today's visit at 1:05 PM who confirmed that medication was not given in the morning. Stated that he called doctor who said to give in the afternoon and check blood pressure and he followed those instructions.
Based on LPA's observations and interviews which were 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) cited on the attached 9099 D.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021
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-20210614162433
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/16/2021
Section Cited
CCR
87465(a)
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Incidental Medical and Dental Care
A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self administered medication as needed.

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Administrator will ensure in service training by pharmacy by POC due date.

Training completed 6/9/21.

Deficiency cleared,.
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This requirement was not met as evidenced by:
Based on documentation and interview licensee failed to provide assistance with self administered medication with Client # 1 missing morning dose of medication Amlodipine Besylate 5 mg which posed an Immediate Health and Safety Risk to resident 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: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2