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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197802587
Report Date: 04/07/2025
Date Signed: 04/07/2025 11:34:54 AM

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:
04/07/2025
UNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Josephine Cochongco - AdministratorTIME COMPLETED:
11:45 AM
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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**** This report supersedes the original complaint report dated 02/18/2025. This report is to correct the deficiency type and regulation section cited on 9099-D page information. The investigation finding remains SUBSTANTIATED. *****

Licensing Program Analyst (LPA), Bennette Pena conducted the subsequent visit to deliver superseded report for the allegations listed above. LPA met with the Administrator, Josephine Cochongco and discussed the purpose of the visit.

The investigation consisted of the following: On 02/18/2025, LPA toured the facility, obtained copies of pertinent documents related to the investigation and interviewed staff & attempted to interview clients. During today's visit, LPA discussed the superseded report regarding the corrections and cleared the deficiencies.****CONTINUED ON LIC 9099-C***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: 04/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025
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: 04/07/2025
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: 04/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025
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: 04/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/08/2025
Section Cited
HSC
80075(b)
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80075 Health Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
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Administrator to conduct a staff training on medication administration and dispensing protocols 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 wherein C-1 had an undispensed routine 11am medication (SOD Chrolide 1 gm tab) that remained in its package, which poses an immediate health and safety risk to clients in care.
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****This report supersedes the original report dated 02/18/2025 to correct the deficiency type to Type A and update the regulation section cited. *****
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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: 04/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3