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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603028
Report Date: 01/17/2023
Date Signed: 01/17/2023 01:24:53 PM

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:
01/17/2023
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Gregg Knapp- LicenseeTIME COMPLETED:
01:35 PM
ALLEGATION(S):
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Uncleared adults are providing care and supervision of residents.
INVESTIGATION FINDINGS:
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***Please note: This LIC9099 report supercedes the LIC9099 report dated 11/29/2022 to include additional information and to change the findings of the initial complaint visit.***

Licensing Program Analyst (LPA) V. Maldonado made an unannounced subsequent 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.

On 11/29/22, 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.
During today's visit, LPA Maldonado obtained a copy of the resident and staff roster and the following documents for Residents# 1-5 (R1-R5): Facesheet and Physician's report. LPA also interviewed R1-R5.

(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: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023
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: 01/17/2023
NARRATIVE
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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. During additional interviews conducted with S1 and S3 on 1/17/22, S1 and S3 stated that if caregivers require assistance with wheeling the residents around or transferring a resident, RL1 helps. Upon entry to the facility on 1/17/23, LPA observed RL1 feeding a resident that was sitting in the dining room. S1-S3 stated that RL1 is not an employee of the facility. S1-S2 stated that RL1 will be leaving in March and is only here visiting. In interviews conducted with R1-R5, (1) of (5) residents confirmed that RL1 assists R4 with care needs.

Based on interviews conducted and records review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, are being cited on the attached LIC 9099D.

Immediate Civil Penalties of $500 are also being issued during today's visit.

An exit interview was held 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: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 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: 01/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/18/2023
Section Cited
CCR
87355(e)(1)
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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review... shall prior to working, residing or volunteering in a licensed facility:(1)Obtain a California clearance or a criminal record exemption as required by the Department...
This requirement was not met as evidenced by:
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The licensee will remove the individual in question from the facility and initiate a criminal background clearance. The documents will be provided to the LPA via email by the POC due date.
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Based on LPA's observations and interviews, the licensee failed to obtain a criminal background clearance for RL1 and associate them to the facility, prior to them residing at the facility and asissting with care of the residents, which poses an immediate 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: 01/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023
LIC9099 (FAS) - (06/04)
Page: 3 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
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:
01/17/2023
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Gregg Knapp- LicenseeTIME COMPLETED:
01:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff are sleeping in the common area.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
***Please note: This LIC9099 report supercedes the LIC9099 report dated 11/29/2022 to clarify the findings of only this allegation; However, the findings will remain the same.***

Licensing Program Analyst (LPA) V. Maldonado made an unannounced subsequent 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.

On 11/29/22, 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.
During today's visit, LPA Maldonado obtained a copy of the resident and staff roster and the following documents for Residents# 1-5 (R1-R5): Facesheet and Physician's report. LPA also interviewed R1-R5.

(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: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
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
VISIT DATE: 01/17/2023
NARRATIVE
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The investigation revealed the following:

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: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5