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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197802587
Report Date: 02/18/2025
Date Signed: 02/18/2025 02:24:26 PM

Substantiated


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
02/13/2025 and conducted by Evaluator Bennette Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250213153643
FACILITY NAME:CULLEN HOMEFACILITY NUMBER:
197802587
ADMINISTRATOR:PENAFRANCIA ORBITAFACILITY TYPE:
735
ADDRESS:14397 CULLEN STREETTELEPHONE:
(562) 696-9694
CITY:WHITTIERSTATE: CAZIP CODE:
90604
CAPACITY:6CENSUS: 4DATE:
02/18/2025
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Josephine Cochongco - AdministratorTIME COMPLETED:
02:27 PM
ALLEGATION(S):
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Staff did not ensure that resident was administered their medication as prescribed.
Staff did not report an incident involving a resident as necessary.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Bennette Pena conducted the initial complaint investigation for the allegations listed above. LPA met with Minerva Cobilla, House Manager and explained the purpose of the visit. At 10:49am, Administrator, Josephine Cochongco arrived and assisted LPA.

The investigation consisted of the following: LPA toured the facility and obtained a copy of the staff & client rosters. LPA reviewed and obtained Client #1 (C1) files such as Face sheet (ID and Emergency Info.), Physician’s report, Medication Administration Records (Jan-Feb 2025) and Incident Report (Jan. 2025). LPA also reviewed obtained files for Staff #4 (S4) - Staff #5 (S5) and the Corrective Action Plan (CAP) addressing the above allegations issued by Eastern Los Angeles Regional Center dated 01/23/2025. Administrator is in agreement with the CAP findings and will be complying with the CAP. Between 10:30am-12:00pm, LPA interviewed Staff #1 (S1)-Staff #3 (S3) and telephonically interviewed Staff #4 (S4). LPA attempted to interview Client #2 (C2) - Client #3 (C3) who were both present in the facility but unsuccessful due to cognitive abilities. Client #1 (C1) and Client #4 (C4) were in the day program therefore not interviewed.****CONTINUED ON LIC 9099-C***



Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025
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 3
Control Number 28-AS-20250213153643
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: CULLEN HOME
FACILITY NUMBER: 197802587
VISIT DATE: 02/18/2025
NARRATIVE
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The investigation revealed the following:

In regards to the allegation: "Staff did not ensure that resident was administered their medication as prescribed." It is alleged that there was one medication error for C1. According to the Corrective Action Plan (CAP) C1 had a missing 11am medication still in packaged and not dispensed. (4) out of (4) staff interviewed corroborated the allegation. S1-S4 indicated that a medication error was identified and reported for C1 when QA from ELARC conducted a routine FMR (Facility monitoring report) on 01/13/2025. All staff interviewed stated that C1 did not receive the scheduled medication. LPA verified this with S1-S4 during the interviews, who all agreed with the findings in the Corrective Action Plan (CAP) and stated they would comply with it, supporting the allegation.

In regards to the allegation: "Staff did not report an incident involving a resident as necessary." It is alleged that there was a lack of SIR per the medication error for C1. Interview with S1 corroborated the allegation. S1 stated that she worked on the incident report but submitted it to the Regional Center's QA after the deadline. S1 indicated that the incident report should have been sent by 01/20/2025, but S1 sent it on 01/30/2025. Based on the CAP of 01/23/2025 and staff interviews, the allegation has been substantiated.

Based on LPA’s interviews and document reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Deficiencies cited on the attached LIC9099-D. Exit interview was conducted and a copy of this report was provided to Josephine Cochongco, Administrator along with the Appeals Rights.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20250213153643
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: CULLEN HOME
FACILITY NUMBER: 197802587
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
02/21/2025
Section Cited
CCR
80075(6)(C)
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80075 Health Related Services
(6) If the client is unable to determine his/her own need for a prescription or nonprescription PRN medication....., shall be permitted to assist the client ..., provided all of the following requirements are met: (C) The date and time the PRN medication was taken, the dosage taken, ...., shall be documented and maintained in the client's facility record.
This requirement is not met as evidenced by:
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Administrator to conduct a staff training on medication administration and dispensing procedures and submit the in-service training log with topics discussed, a sign in sheet of those in attendance to LPA/CCL by POC due date.
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Based on staff interviews and document reviews, the Administrator did not comply with the section cited above in which C-1 had a missing 11am medication still in packaged and not dispensed which poses a potential health and safety risk to clients in care.
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Type B
02/21/2025
Section Cited
CCR
80061(b)
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Reporting Requirements. Upon the occurrence, during the operation of the facility, of any of the events specified in (1) ..... In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. This requirement was not met evidenced by:
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Administrator shall ensure all incident reports are reported within the required timeline. Administrator agreed to provide a written plan to correct the issues, which will explain the facility's reporting protocols. This plan and a copy of the incident report will be sent to CCL/LPA by POC due date.
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Based on interviews and document reviews, a medication error incident was discovered on 01/13/2025 by QA and Administrator failed to send an incident report to Regional Center and CCL within 7 days of occurrence as required which poses a potential health and safety risk to clients 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: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3