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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603028
Report Date: 11/29/2022
Date Signed: 11/29/2022 11:59:12 AM

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
11/21/2022 and conducted by Evaluator Valeria Maldonado
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221121142959
FACILITY NAME:PEACEFUL GARDENSFACILITY NUMBER:
198603028
ADMINISTRATOR:KNAPP, GREGG AFACILITY TYPE:
740
ADDRESS:1033 E VIRGINIA AVETELEPHONE:
(909) 406-3711
CITY:GLENDORASTATE: CAZIP CODE:
91741
CAPACITY:6CENSUS: 5DATE:
11/29/2022
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Gregg Knapp- AdminstratorTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility staff are not adequately trained.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced initial complaint visit to the facility for the purpose of investigating the above-mentioned allegations. LPA Maldonado met with administrator Gregg Knapp and explained the purpose for the visit.

During the visit, LPA Maldonado obtained a copy of the resident and staff roster. LPA also conducted a tour of the physical plant with Staff# 2 and reviewed files for Staff# 1-4 (S1-S4). S1-S3 were interviewed.

The investigation revealed the following:
Regarding allegation- Facility are not trained adequately.
LPA interviewed S1 who admitted that staff have not yet received their required annual training. S1 stated that the facility is experiencing staffing issues and new staff have recentlly been hired; However, there is a language barrier with the staff, which makes it difficult for them to complete their training.
(Report Continued on LIC9099-C...)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
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 5
Control Number 28-AS-20221121142959
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: 11/29/2022
NARRATIVE
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After review of staff files, it was discovered that staff do not have proof of required annual training certification for the year 2022. During the interviews conducted with S2-S3, it was also confirmed that no annual required training has been completed this year. S2 stated that Hospice and Home Health agencies usually come to the facility to provide in-service training; However, there is no file kept in the facility to keep proof of training provided/obtained.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the allegations are found to be substantiated. The deficiencies are being cited on the attached LIC9099-D.

An exit interview was conducted with administrator Gregg Knapp and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
11/21/2022 and conducted by Evaluator Valeria Maldonado
COMPLAINT CONTROL NUMBER: 28-AS-20221121142959

FACILITY NAME:PEACEFUL GARDENSFACILITY NUMBER:
198603028
ADMINISTRATOR:KNAPP, GREGG AFACILITY TYPE:
740
ADDRESS:1033 E VIRGINIA AVETELEPHONE:
(909) 406-3711
CITY:GLENDORASTATE: CAZIP CODE:
91741
CAPACITY:6CENSUS: 5DATE:
11/29/2022
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Gregg Knapp- AdminstratorTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Uncleared adults are providing care and supervision of residents.
Facility staff are sleeping in the common area.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced initial complaint visit to the facility for the purpose of investigating the above-mentioned allegations. LPA Maldonado met with administrator Gregg Knapp and explained the purpose for the visit.

During the visit, LPA Maldonado obtained a copy of the resident and staff roster. LPA also conducted a tour of the physical plant with Staff# 2 and reviewed files for Staff# 1-4 (S1-S4). S1-S3 were interviewed.

The investigation revealed the following:
Regarding allegation- Uncleared adults are providing care and supervision of residents.
During interviews conducted with S1-S3, (3) of (3) staff stated that S2 has a relative (RL1) that is currently staying at the facility and sleeping there. S1 stated that RL1 has been at the facility for about 3 weeks and helps with cooking and cleaning- no direct care is being provided to residents and RL1 is never left unsupervised with the residents. (Report Continued on LIC9099-C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20221121142959
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: 11/29/2022
NARRATIVE
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S1-S3 stated that RL1 is not an employee of the facility. RL1 will be leaving in a few months and is only here visiting.

Regarding allegation- Facility staff are sleeping in the common area.
During interviews conducted with S1-S3, it was stated that there are no live-in staff other than the licensees. Although RL1 is currently staying at the facility, RL1 has a room to sleep in. During the tour of the physical plant, LPA observed all rooms in the home to accommodate residents, whom all reside on the first floor, and licensees and RL1 on the second floor. LPA observed a single foldable bed in one of the bedrooms upstairs where RL1 is currently staying and some belongings. LPA did not observe any makeshift rooms or beds anywhere in or throughout the home/property.

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.

An exit interview was held with administrator Gregg Knapp and a copy of the report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20221121142959
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2022
Section Cited
CCR
87412(c)(1)(2)A(B)
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87412 Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.(1) ...staff training...shall be documented:(A)...there shall be...ten hours of initial training within the first four weeks of employment, and...four hours of training annually thereafter...in the content areas as specified in Section 87411(c)(2).(B)For staff who provide direct care to residents with dementia...1.The orientation received as specified in Section 87707(a)(1).2.The in-service training received as specified in Section 87707(a)(2)
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Licensee will ensure staff obtain the required annual training and provide proof of completion to LPA via email by the POC due date: 12/29/22.
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This requirement was not met as evidenced by:
Based on observation, interview, and records review, licensee has failed to provide proof of required annual training certification for all staff, which poses a potential Health, Safety, or Personal Rights risk to persons 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.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5