197606347-1-30-2024-28-AS-RORN-D3AMUZ-20240312095553

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606347
Report Date: 01/30/2024
Date Signed: 01/30/2024 03:18:59 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
01/23/2024 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240123083006

FACILITY NAME:	COGSWELL GARDEN HOME		FACILITY NUMBER:	197606347
ADMINISTRATOR:	LILIAN C. SALMORIN		FACILITY TYPE:	740
ADDRESS:	5405 N. COGSWELL ROAD		TELEPHONE:	(626) 444-3523
CITY:	EL MONTE	STATE: CA	ZIP CODE:	91732
CAPACITY:	15	CENSUS: 8	DATE:	01/30/2024
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Staff Arni Castillo		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff did not follow PKU diet orders for residents
Staff did not implement the IPP for residents
Administrator did not assess the needs of residents prior to placement.

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 allegations above.
On today's visit LPA met with Staff Arni Castillo. LPA received a Corrective Action Plan report from the SG/Pomona Regional Center dated January 22, 2024. The report states that the facility was unaware Client's C1 and C 2 were on a PKU diet and did not know what it was and needed to be on a special diet.
This information was included in the IPP Risk Section for the reports written for 2016, 2019 and 2022.
At today's visit staff and resident roster was submitted.
Interview was conducted telephonically with Administrator Lillian Salmorin at 1:45 PM.
Interview was conducted with Staff S 1 at 2:00 PM.
Interview was conducted with Client C1 at 2:45 PM. Client C 2 was in the hospital.
In regards to the allegation Staff did not follow PKU diet orders for residents, based on interviews conducted and information gathered the Administrator stated that it is true that they did not follow PKU diet orders and was unaware of it. Staff S 1 stated that it was true that they were unaware

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: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

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 3

Control Number 28-AS-20240123083006

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: 01/30/2024

NARRATIVE

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of a PKU diet, but once Regional Center told them they implemented it.
Interview with Client C 1 who stated he gets all his meals and is aware that he needs to be on a PKU diet.
It should be noted that San Gabriel Pomona Regional Center on Corrective Action Plan 01/22/24 had substantiated findings.
Review of files for C1 and C2 noted that they have PKU and needed to be on a special diet.
In regards to the allegation Staff did not implement the IPP for residents, based on interviews conducted and information gathered, Administrator stated that she did not implement what was in the Initial Program Plan (IPP) in which the information was included in the IPP Risk Section for the reports written for 2016, 2019 and 2022.
Interview with Staff S 1 who confirmed that they did not implement what was in Client C1 and C2's Initial Program Plan (IPP).
It should be noted that San Gabriel Pomona Regional Center Corrective Action Plan 01/22/24 had substantiated findings.
In regards to the allegation Administrator did not assess the needs of residents prior to placement, based on interviews conducted and information gathered Administrator stated that she had failed to review 2016 IPP prior to placement for C1 and C2.
Interview with Staff S 1 who confirmed that the IPP was not reviewed for Client's C 1 and C 2 prior to placement.
Interview with Client C 1 who stated he is on a PKU diet per doctor's orders.
It should be noted that San Gabriel Pomona Regional Center on Corrective Action Plan 01/22/24 had substantiated findings.
Based on observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the allegations Staff did not follow PKU diet orders for residents, Staff did not implement the IPP for residents, and Administrator did not assess the needs of residents prior to placement. are found to be Substantiated. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20240123083006

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: 01/30/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type B 02/02/2024 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities Residents in all residential care facilities for the elderly shall have all of the following personal rights: to be accorded safe, healthful and comfortable accommodations, furnishings and equipment.	1 2 3 4 5 6 7	Administrator will conduct training for all staff which covers reviewing IPP's and reviewing PKU diets. Log of those who attended will be submitted to Licensing by POC due date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: review of Corrective Action Plan, and interviews conducted the facility did not follow a PKU diet, did not implement IPP and did not review IPP prior to placement for C 1 and C 2 which poses a potential health and safety risk for clients in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC9099 (FAS) - (06/04)

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