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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603035
Report Date: 09/15/2025
Date Signed: 09/15/2025 12:06:40 PM

Substantiated


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
09/11/2025 and conducted by Evaluator Daniel Konishi
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250911115557
FACILITY NAME:PUENTE HOMEFACILITY NUMBER:
198603035
ADMINISTRATOR:MELISSA VAZQUEZFACILITY TYPE:
737
ADDRESS:1423 E PUENTE AVETELEPHONE:
(626) 331-6331
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY:4CENSUS: 4DATE:
09/15/2025
UNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Ronnie Chua, AdministratorTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff did not administer residents medication as directed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Initial 10-Day complaint investigation visit regarding the above allegation. LPA discussed the purpose of the visit with Administrator, Ronnie Chua.

The investigation consisted of the following: LPA requested a copy of staff and client rosters. LPA interviewed Admin, Staff #1 (S1) to Staff #4 (S4), and Client #1 (C1). LPA attempted to interview Client #2 (C2) but was unable since C2 declined to be interviewed. LPA attempted to interview Client #3 (C3) over the phone but was unable since C3 was unable to answer questions. LPA was unable to interview Client #4 (C4) since C4 is at the hospital. LPA reviewed medication records for C1. LPA docs requested C1 file: Face sheet, Physician’s Orders, and Medication Administration Records (June 2025 to Sept 2025), and a Special Incident Report. LPA requested copies of S1’s file such as: First Aid training and medication training. The Administrator will send S1’s corrective action and staff training by COB. LPA also obtained staff in-service training documents and personnel report. LPA also reviewed four (4) clients’ medications.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025
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 3
Control Number 28-AS-20250911115557
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: PUENTE HOME
FACILITY NUMBER: 198603035
VISIT DATE: 09/15/2025
NARRATIVE
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The investigation revealed the following in regards to the allegation: “Staff did not administer residents medication as directed.” It is alleged that the staff did not dispense medications for C1’s medication Topiramate Tab 50MG tablet in the morning of 08/29/2025. LPA interviewed C1 that denied the allegation stating that there was no issues regarding receiving medications. LPA interviewed four (4) out of five (5) staff that corroborated with the allegation stating that a medication error did occur on 08/29/2025. One (1) out of five (5) staff interviewed could not confirm nor deny the allegation stating not being able to recall an medication error incident occurred on 08/29/20025. Four (4) out of five (5) staff interviewed stated the reason why the medication Topiramate Tab 50MG was not administered because it did not scan onto the Quick MAR prior to handing that medication to C1 and C1 left the facility at 7:15am, so there was not enough time for the medication to be given. However, four (4) out of five (5) staff stated that there is an alternate way of processing the medications on the Quick MAR by manually entering the medication using the mouse if the scanning did not work. Per Administrator, S1 did not do the alternate way of processing the medication on 08/29/2025. LPA reviewed the Special Incident Report dated 08/31/2025 which confirms that the staff did not administer Topiramate Tab 50mg at the scheduled time to C1 on the morning of 08/29/2025. In addition, SGPRC (San Gabriel Pomona Regional Center) conducted an investigation regarding this allegation which was substantiated. LPA reviewed the facility’s Registered Nurse re-trained medication pass training for S1 on 09/11/2025. Per Administrator, S1 was placed on a 30-day administrative oversite. Five (5) out of five (5) staff interviewed also stated that the facility now conducts a 15-minute post check every time medications are passed to all clients. Per Administrator, the facility has two (2) staff that are involved in medication administration to the clients. LPA reviewed four (4) clients’ medications that are centrally stored and bubble packed. Based on observations, record review, and interviews conducted with facility staff, and facility residents, there was sufficient supportive evidence to concur with the reported allegation.

A civil penalty in the amount of $ 250.00 is being issued during today's visit as a result of a repeat citation within the past 12 months.

Based on LPA interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. An exit interview was conducted with the Administrator, Ronnie Chua. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20250911115557
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: PUENTE HOME
FACILITY NUMBER: 198603035
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/16/2025
Section Cited
CCR
80075(b)
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(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
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The administrator will retrain staff that pass out medications and will submit training materials and sign in sheets discussed to the LPA by the POC due date.
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This requirement is not met with facility during a visit on 8/29/2025, based on record review, the staff failed to administer medication as prescribed on 08/29/2025 the medication Topiramate Tab 50MG tablet was not dispensed for Client #1 (C1). The medication error was not documented in the MAR. Special Incident Report dated 08/31/2025 confirms that a medication error occurred in which the medication Topiramate Tab 50MG tablet was not dispensed for C1 on 08/29/2025. This 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.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3