198603028-6-5-2020-28-AS-MVAO-BQFRYZ-20200610132709

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603028
Report Date: 06/03/2020
Date Signed: 06/05/2020 10:19:57 AM

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
06/01/2020 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200601160339

FACILITY NAME:	PEACEFUL GARDENS		FACILITY NUMBER:	198603028
ADMINISTRATOR:	KNAPP, GREGG A		FACILITY TYPE:	740
ADDRESS:	1033 E VIRGINIA AVE		TELEPHONE:	(909) 406-3711
CITY:	GLENDORA	STATE: CA	ZIP CODE:	91741
CAPACITY:	6	CENSUS: 5	DATE:	06/03/2020
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Administrator, Gregg Knapp		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Resident is not being provided adequate food while in care.
Resident is not being treated with respect/dignity while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vasallo initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Gregg Knapp, the facility administrator.

LPA Vasallo conducted telephone interviews with the administrator, 3 residents, 1 caregiver, and a video call which consisted of a review of the food supply and physical plant. LPA also requested and obtained copies of resident and staff rosters via email.

The investigation revealed the following: Staff interviewed deny the allegations. They said there is plenty of food and everyone is treated with respect. Interviews with Resident #1 (R1) and Resident #2 (R2) revealed that there is plenty of food and the food is of good quality. Both residents enjoy living in the facility. Resident #3 (R3) had limited speech, but indicated he/she is happy there and does not want to go home.
Continued on 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20200601160339

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: PEACEFUL GARDENS	FACILITY NUMBER: 198603028
	VISIT DATE: 06/03/2020

NARRATIVE

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LPA observed the physical plant using video call. The kitchen was observed to have 2 refrigerators and both had a good amount of food. There were meats, vegetables, beverages and dairy products. The facility pantry had plenty of dry and canned goods. LPA observed the living room where residents were watching television and coloring. LPA also observed residents' bedrooms.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

A telephonic exit interview was conducted with Gregg Knapp, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2020

LIC9099 (FAS) - (06/04)

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