198603028-3-14-2023-28-AS-LHIS-CUPRGB-20230814130028

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603028
Report Date: 03/14/2023
Date Signed: 03/14/2023 03:17:30 PM

Unsubstantiated

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
03/09/2023 and conducted by Evaluator Alberto Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230309083614

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: 4	DATE:	03/14/2023
		UNANNOUNCED	TIME BEGAN:	09:54 AM
MET WITH:	Gregg Knapp, Administrator		TIME COMPLETED:	03:22 PM

ALLEGATION(S):

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Staff did not follow proper infection control practices
Residents incontinence needs are not properly met by facility staff

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alberto Lopez made an unannounced complaint visit to the facility for the purpose of investigating the above-mentioned allegations. LPA Lopez met with administrator Gregg Knapp and explained the purpose for the visit.

The investigation consisted of interviews with 4 staff (S1-S4), 2 residents (R1-R2) and Witness W1-W2
LPA reviewed and obtained pertinent medical information for all 4 residents and infection control plan..

Regarding Allegation: Staff did not follow proper infection control practices. It is alleged that facility is not following proper infection control practices and are sharing medical equipment without proper sanitation of equipment and has caused the other residents to get sick.

(Continued on 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

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-20230309083614

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: PEACEFUL GARDENS	FACILITY NUMBER: 198603028
	VISIT DATE: 03/14/2023

NARRATIVE

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The investigation revealed that medical equipment is not being shared with other residents. LPA interviewed 4 staff (S1-S4) and 4 of 4 staff stated that medical equipment is not shared between residents. S1 stated that face mask on nebulizer is cleaned with water and then wiped down with cleansing wipes and dried and the plastic face mask is replaced every month with a new one. S1 demonstrated cleaning of nebulizer to LPA during visit. Administrator S2 stated that residents are sent nebulizer from hospice and it is only used for that specific resident. 2 of 2 residents interviewed stated that they are not aware that nebulizer has been shared with other residents and R2 stated R2 has not used a nebulizer. W1 and W2 are not aware of facility using shared nebulizer There is no evidence that the nebulizer is being shared between residents at time of visit.

Regarding Allegation: Residents incontinence needs are not properly met by facility staff

It is alleged that residents are forced to sit on toilet until they have bowel movement in order to keep the bedding clean and residents are developing cyanotic extremities.

The investigation revealed that none of the residents have developed cyanotic extremities. LPA visually verified this for all residents during visit. 4 out of 4 staff interviewed denied that residents are left on the toilet for hours. LPA observed two residents been helped to restroom for toilet use during visit and it took between 3 ½ minutes to 4 minutes and 15 seconds and two staff assisted residents. A record is kept for each resident’s bowel movement as a precautionary. 2 of 2 residents stated that they are assisted to the restroom but not left on toilet for hours. W1 and W2 could not collaborate the allegation. There was no evidence at the time of visit to support the allegation.

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

LIC9099 (FAS) - (06/04)

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