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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603035
Report Date: 11/21/2024
Date Signed: 11/21/2024 12:23:22 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
11/15/2024 and conducted by Evaluator Daniel Konishi
COMPLAINT CONTROL NUMBER: 28-AS-20241115123529
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:
11/21/2024
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Aniema Akpanudosen, RBTTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Licensee did not ensure client received medical services as needed.
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 Staff #1 (S1).
The investigation consisted of the following: LPA requested a copy of staff and client roster. LPA interviewed Assistant Admin, S1 to Staff #3 (S3), Client #1 (C1) to Client #3 (C3) and Witness #1 (W1). LPA attempted to interview Client #4 (C4) but was unable to interview since C4 was out of the facility and busy. LPA also reviewed and requested copies of C1’s file documents such as Physician’s Orders, Physician’s Report, Appraisal Services and Needs Plan, Functional Capability Assessment, Face Sheet, IPP (Individual Program Plan), and BiPAP machine log.

The investigation revealed the following: Regarding allegation: Licensee did not ensure client received medical services as needed. It is alleged that C1’s BiPAP machine was not replaced nor fixed in a timely manner placing C1’s health and safety at risk.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
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-20241115123529
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: 11/21/2024
NARRATIVE
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Based on the interviews of Assistant Administrator, S1 to S3, W1, and C1 all confirm that the BiPAP machine was inoperable on September 14th, 2024 due to property damage from C1 and not replaced with working a BiPAP machine until November 7th, 2024. C1 has been transferred to the hospital and nursing facilities to use a working BiPAP machine. However, C1 did not have a working BiPAP machine at Puente Home until the facility was able to get a rental Bi-PAP machine on November 7th, 2024. Based on interviews of the Assistant Administrator, S1 to S3, and W1, all confirm that there were dates when C1 did return to Puente Home and C1 did not have a BiPAP machine which is needed. Currently, C1 has a working BiPAP machine as a rental. Assistant Administrator stated for C1 to get a new BiPAP machine, C1 must do a sleep study which was scheduled on November 15th, 2024. Assistant Administrator and W1 also stated that C1 and Regional Center are both working on getting a new BiPAP machine.

San Gabriel Pomona Regional Center also conducted an investigation on November 1st, 2024. It was reported that the BiPAP machine was broken on August 7th, 2024. BiPAP logs on when it was used was inconsistent. Staff shared that the BiPAP machine had been broken for several months. Based on the San Gabriel Pomona Regional Center’s investigation, it revealed that the BiPAP machine had not been working since August 7th, 2024 to present time.

Based on LPA's interviews conducted and record 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 and Chapter 8 are cited on the attached LIC 9099D.

An exit interview was conducted with the S1. A copy of the report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20241115123529
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: 11/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/22/2024
Section Cited
CCR
80075(a)
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(a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.

This requirement is not met as evidenced by:
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Licensee will ensure that client’s receive medical services as need. POC has been cleared as C1 has received a working BiPAP machine on 11/07/2024.
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Per investigation, facility did not repair or replace C1’s BiPAP machine in a timely manner 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.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3