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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603035
Report Date: 05/18/2022
Date Signed: 05/18/2022 05:38:22 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
05/16/2022 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220516144706
FACILITY NAME:PUENTE HOMEFACILITY NUMBER:
198603035
ADMINISTRATOR:YASHICA MORROWFACILITY TYPE:
737
ADDRESS:1423 E PUENTE AVETELEPHONE:
(909) 596-5360
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY:4CENSUS: 3DATE:
05/18/2022
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Henry Ray Scott-Lead StaffTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Facility does not adhere to COVID-19 protocol
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Wong conducted an unannounced initial 10 days complaint investigation and addressed the above allegation. LPA met with the staff John Mejia and explained the reason of the visit. The administrator and program director also assisted LPA's visit via telephone.

The investigation consisted of the following: LPA interviewed administrator and program director via telephone, four staff (S1-S4) and three clients (C1-C3). LPA also reviewed all clients' files, visitors log for COVID-19, staff CPI training and obained copy of C1's Individual Program Plan (IPP).

The investigation revealed of the following: Allegation1 "Facility does not adhere to COVID-19 protocol." While LPA arrived the facility, LPA observed one of the staff and one client are not wearing mask and the home is currently having a positive case in the facility. While LPA interviewed staff, the staff would take off the mask and talk to LPA.
(See LIC 9099C for continaution)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022
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-20220516144706
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: PUENTE HOME
FACILITY NUMBER: 198603035
VISIT DATE: 05/18/2022
NARRATIVE
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In addition, LPA also reviewed the visitor log for April and May, 2022 and Visitor Screening Tool, there were about 31 visitors from April 20 to May 18, 22, but LPA only saw about 5 visitors completed the Visitor Screening Tool.

Based on the interviews conducted with the clients and staff, record review and LPA's observation, Based on LPA's observations and interviews conducted the preponderance of evidence standard has been met, therefore the above allegations are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview conducted. A copy of the report and appeal right was provided to Lead Staff- Henry Ray Scott.
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 28-AS-20220516144706
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: PUENTE HOME
FACILITY NUMBER: 198603035
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/25/2022
Section Cited
CCR
85095.5(a)(5)
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85095.5 Infection Control Requirements(a)A licensee shall ensure that infection control practices are maintained as follows:(5)(5) All staff and volunteers, regardless of having direct contact with clients, shall practice and maintain respiratory etiquette as specified below to minimize exposure to potential illness.
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The facility will ensure the staff would follow the infection control pratices and the administrato will retrain the staff for infection control and will send the training log to LPA by POC due date
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The requirement was not met as evidenced by LPA's observation, LPA observed staff and client did not wear mask while LPA arrived at the facility. LPA also observed staff took of the mask while LPA interviewed and for record review, there's no visitor screening tool completed.
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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.
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022
LIC9099 (FAS) - (06/04)
Page: 4 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
05/16/2022 and conducted by Evaluator Christine Wong
COMPLAINT CONTROL NUMBER: 28-AS-20220516144706

FACILITY NAME:PUENTE HOMEFACILITY NUMBER:
198603035
ADMINISTRATOR:YASHICA MORROWFACILITY TYPE:
737
ADDRESS:1423 E PUENTE AVETELEPHONE:
(909) 596-5360
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY:4CENSUS: 3DATE:
05/18/2022
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:TIME COMPLETED:
05:45 PM
ALLEGATION(S):
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9
Facility is not able to meet residnet's needs
Staff speak inappropriately to resident.
INVESTIGATION FINDINGS:
1
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13
Licensing Program Analyst (LPA) Christine Wong conducted an unannounced initial 10 days complaint investigation and addressed the above allegations. LPA met with the staff John Mejia and explained the reason of the visit. The administrator and program director assited LPA's visit via telephone.

The investigation consisted of the following: LPA interviewed administrator and program director via telephone, four staff (S1-S4) and three clients (C1-C3). LPA also reviewed all clients' files, visitors log for COVID-19, staff CPI training and obained copy of C1's Individual Program Plan (IPP).

The investigation revealed of the following: Allegation#1 "Faciltiy is not able to meet resident's needs." LPA interviewed three clients and two out of three reported the faciltiy is able to meet their needs. They feel safe living in the home. LPA interviewed administratrator and program director and reported C1 did have the suicidal attempt once and they did follow the protocol.
(See LIC 9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20220516144706
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: PUENTE HOME
FACILITY NUMBER: 198603035
VISIT DATE: 05/18/2022
NARRATIVE
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The facility did contact C1's therapist immediately and the therapist did evaluate C1 situation on the phone and stated that she was not in crisis. The facility staff just had to continue to monitor C1 closely. The administrator also reported C1 is currently receiving three therapy/counseling session once a week and monthly and two behavioral therapy weekly. The program director and administrator reported that C1 receives a lot of support from facility staff, medical team and regional center.

Allegation#2" Staff speak inappropriately to residents." LPA interviewed three clients and two out of three clients denied the allegation and reported staff never yelled or cursed at them. Staff are nice people. LPA interviewed staff and staff reported only client speak inappropriately to them. Client would say hurtful, bad and mean things to them. The administrator also reported they would never tolerate staff doing that to clients.

Based on the interviews with client and staff, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED

Exit Interview conducted and a copy of this report and appeal right was provided to the Lead Staff- Henry Ray Scott. .
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5