198603028-5-1-2026-28-AS-WSHO-DTRS42-20260504133200

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603028
Report Date: 05/01/2026
Date Signed: 05/01/2026 01:46:22 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
01/14/2026 and conducted by Evaluator Blanca Gonzalez

COMPLAINT CONTROL NUMBER: 28-AS-20260114123554

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:	0	CENSUS:	DATE:	05/01/2026
		UNANNOUNCED	TIME BEGAN:	12:34 PM
MET WITH:	Gregg Knapp		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Resident sustained unexplained injury due to staff neglect/lack of supervision.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced subsequent complaint investigation visit to deliver findings for the allegation above. LPA met with *** and explained the reason for the visit.
The investigation consisted of the following: On 01/21/26 LPA Gonzalez conducted an initial complaint investigation visit , requested and obtained copies of staff roster, client roster, and the following documents for R1: admission agreement, face sheet, physician’s report, medication list, needs/services care plan, functional capabilities, Advanced Health Care Directive, Hospice Care Plan, Hospice patient authorization, Hospice medication profile, and caregiver notes. On 01/23/26 the Department interviewed reporting party and requested records from Glendora PD. On 01/27/26, the Department interviewed staff #1-#2 (S1-S2), and resident #1 (R1). On 02/02/26 the Department interviewed staff #3 (S3). On 02/17/26 the Department interviewed R1’s family member.
continued on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Blanca Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2026

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-20260114123554

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PEACEFUL GARDENS	FACILITY NUMBER: 198603028
	VISIT DATE: 05/01/2026

NARRATIVE

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The investigation revealed the following: Regarding allegation “Resident sustained unexplained injury due to staff neglect/lack of supervision” it was reported that R1 was observed to have several unexplained bruises to the body including bruises to the chin, left temple and a large black and purple bruise located on the inner thigh, halfway to the knee. Based on file review and interviews conducted by the Department, there was insufficient evidence to suggest the bruising on R1 was a result of staff neglect. R1 has a known behavior of climbing over bed rails and getting out of bed. At the time of bruising, there were no doctor’s orders for 1:1 supervision. S1 stated they believe that the medications R1 was taking may have contributed to R1 being more of a fall risk and increase R1’s chances of bruising when R1’s skin touches the rails on her bed, walls, wheelchair handles, etc. Due to cognitive ability, R1 was not able to answer the investigator’s questions. R1’s family do not feel staff was negligent and feel staff is caring for R1 appropriately.

Based on interviews and record review, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted, and a copy of this report was provided to Gregg Knapp.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Blanca Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2026

LIC9099 (FAS) - (06/04)

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