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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603035
Report Date: 03/13/2025
Date Signed: 03/13/2025 05:17:03 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
03/07/2025 and conducted by Evaluator Daniel Konishi
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250307153234
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:
03/13/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Melissa Vazquez, AdministratorTIME COMPLETED:
05:20 PM
ALLEGATION(S):
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Staff mismanaged resident medication.
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, Melissa Vazquez.

The investigation consisted of the following: LPA requested a copy of staff and client rosters. LPA interviewed Admin, Staff #1 (S1) to Staff #3 (S3), and Client #1 (C1) to Client #4 (C4). LPA reviewed medication records for C1 to C2. LPA docs requested C1 and C2’s file: Face sheet, Physician’s Orders, Medication Administration Records (MAR - December 2024 to March 2025), and IPP. LPA requested copies of S1 and S2’s file such as: valid First Aid, CPI training, and corrective action forms, and medication training. LPA also obtained staff training documents and personnel report.

[Continued on LIC-C]
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
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 5
Control Number 28-AS-20250307153234
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: 03/13/2025
NARRATIVE
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The investigation revealed the following in regards to the allegation: “Staff mismanaged resident medication.” It is alleged that on 12/26/2024, client medications and the Medication Administration Records (MAR) were reviewed and checked against the physician’s prescriptions. The following issue was identified during that review: On 12/25/2024 Medication Metropol 25mg and Lithium Carb 300 mg was not dispensed for C1. The medication error was not identified by the DSP or Administrator prior to the evaluation nor was the incident documented in the MAR or Client Notes. 3 out of 3 staff interviewed cannot recall nor confirm of staff mismanaging resident medication. 3 out of 4 clients denied the allegation. 1 out of 4 clients stated that the staff mismanage medications by providing them at a same date but different time. Based on interview, Administrator stated at that time medication is dispensed through bubble packs at the home but the hospital provided 30-day supply of pill bottles for C1 which caused confusion for the staff that dispense medications. Administrator stated that all required medications were administered. In addition, SGPRC conducted an investigation regarding this allegation which was substantiated. As a result of this, the Administrator re-trained medication management S1 for 2/6/2025 and S2 for 2/20/2025 and placed both S1 and S2 on a 60-day administrative oversite. 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.

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, Melissa Vazquez. 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: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20250307153234
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: 03/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/14/2025
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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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 1/16/2025, based on record review, the staff failed to administer medication as prescribed on 12/26/2024, client medications and the Medication Administration Records (MAR) were reviewed and checked against the physician’s prescriptions. The following issue was identified during that review: On 12/25/2024 Medication Metropol 25mg and Lithium Carb 300 mg was not dispensed for C1. The medication error was not identified by the DSP or Administrator prior to the evaluation nor was the incident documented in the MAR or Client Notes. 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.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5
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
03/07/2025 and conducted by Evaluator Daniel Konishi
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250307153234

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:
03/13/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Melissa Vazquez, AdministratorTIME COMPLETED:
05:20 PM
ALLEGATION(S):
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Staff did not follow reporting requirements.
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, Melissa Vazquez.

The investigation consisted of the following: LPA requested a copy of staff and client rosters. LPA interviewed Admin, Staff #1 (S1) to Staff #3 (S3), and Client #1 (C1) to Client #4. LPA reviewed medication records for C1 to C4. LPA docs requested C1 and C2’s file: Face sheet, Physician’s Orders, Medication Administration Records (MAR - December 2024 to March 2025), and IPP. LPA requested copies of S1 and S1’s file such as: valid First Aid, CPI training, and corrective action forms, and medication training. LPA also obtained staff training documents and personnel report.

[Continued in LIC]
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20250307153234
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: 03/13/2025
NARRATIVE
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The investigation revealed the following in regards to the allegation: “Staff did not follow reporting requirements.” It is alleged that the facility failed to submit the Special Incident Reports (SIRs) to the department for the following dates for C1: 7/31/2024, 9/6/2024, 9/30/2024, 10/1/2024, 11/11/2024 and for C2: 7/20/2024, 8/20/2024, and 10/7/2024. 3 out of 3 staff interviewed indicated that the Administrator handles the Special Incident Reports. LPA reviewed SIRs that have been submitted from the facility to the department and confirmed on the dates listed the department received the Special Incident Reports for the listed above. Based on observations, record review, and interviews conducted with facility staff, and facility residents, there was no sufficient supportive evidence to concur with the reported allegation.

Based on LPA interviews which were conducted and record review, the preponderance of evidence standard has not been met, therefore the above allegation(s) is found to be UNSUBSTANTIATED.

An exit interview was conducted with the Administrator, Melissa Vazquez. 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: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5