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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603460
Report Date: 09/26/2023
Date Signed: 09/26/2023 10:46:57 AM

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
09/15/2021 and conducted by Evaluator Valeria Maldonado
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210915121120
FACILITY NAME:ST. SHARBEL'S GARVEYFACILITY NUMBER:
198603460
ADMINISTRATOR:MUNZON, PETERFACILITY TYPE:
735
ADDRESS:2007 E GARVEY AVE NTELEPHONE:
(562) 682-7027
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY:6CENSUS: 4DATE:
09/26/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Wilfreda Langa- Direct Support Staff (DSP)TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Resident's mattress was not placed appropriately.
INVESTIGATION FINDINGS:
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**Please note: This report will supersede the original report dated: 9/11/23, to include client interview information, and to change the findings for the allegation: Resident's mattress was not placed appropriately., which will be changed to: Substantiated.**

Licensing Program Analyst (LPA) V. Maldonado made an unannounced subsequent visit at the facility for the purpose of completing the investigation regarding the above-mentioned allegation. LPA Maldonado met with Direct Support Professional (DSP), Wilfreda Langa and explained the purpose for the visit.
On 09/23/2021, LPA Kruz Long made an initial complaint visit, which consisted of obtaining a copy of the Staff schedule/Client Roster and requested a copy of the Food Menu, Client #1's Facesheet, Physician's Report, Regional Center Meeting Records, Individual Program Plan, Preplacement Appraisal, Medications Record (MAR), Dental Appointment Records, Weight Chart and P & I Records to be faxed to LPA.LPA Long also conducted interviews with Staff# 1 (S1) and toured Client# 1's (C1) bedroom.
(Report Continued on LIC9099-C...)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023
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 6
Control Number 28-AS-20210915121120
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: ST. SHARBEL'S GARVEY
FACILITY NUMBER: 198603460
VISIT DATE: 09/26/2023
NARRATIVE
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On 09/11/23, LPA Maldonado obtained a copy of the staff schedule/client roster, and a copy of the documents initially requested by LPA Long, due to LPA Maldonado not being provided with them prior to the visit. Interviews were also held with Staff# 2 (S2), attempted interviews with Clients# 3-4 (C3-C4), and a telephonic interview was held with C1’s previous placement agency, Service Coordinator (SC). LPA was unable to interview C1 due to C1 no longer residing at the facility, and unable to interview C2 due to C2 being out in the community during the visit. A tour of the physical plant was also conducted with assistance of Administrator Peter Munzon, with special focus on C1’s old bedroom.
On 9/26/23, LPA Maldonado conducted telephonic interviews with C1 and C2 at their respective programs.

The investigation revealed the following:
Regarding allegation: Resident's mattress was not placed appropriately.
It is alleged that during a visit at the facility on 08/04/21, C1’s family noted that C1’s bed did not feel right and found the spring side of the mattress to be on the up-side. S1 stated C1’s family brought this to their attention and S1 noted that staff were cleaning the mattress and accidentally left it on the wrong side but corrected it immediately. Moreover, S1 decided to purchase a new mattress for C1, but was unable to use it due to C1 moving out of the facility following the complaint. During the tour of the facility conducted during the visit on 9/11/23, LPA Maldonado inspected C1’s old bedroom and observed the new mattress still in the plastic wrap, placed on top of C1’s old bed. LPA also observed all client rooms to be fully furnished with all the required furniture. S2 stated to not have been at the facility when the incident occurred. However, S2 was made aware of it and stated that S1 purchased a new bed altogether, for C1. But, C1 left before the new bed was delivered. (4) of (4) clients interviewed could not corroborate the allegation. C1 stated to have liked C1's room while living at the facility, but could not provide details or recall issues with C1's bed mattress being on the up-side.

Based on LPA's observations and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is Substantiated.

Per California Code of Regulations, Title 22, deficiencies will be cited on the LIC9099-D.

An exit interview was conducted with DSP, Wilfreda Langa, and a copy of the report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
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
09/15/2021 and conducted by Evaluator Valeria Maldonado
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210915121120

FACILITY NAME:ST. SHARBEL'S GARVEYFACILITY NUMBER:
198603460
ADMINISTRATOR:MUNZON, PETERFACILITY TYPE:
735
ADDRESS:2007 E GARVEY AVE NTELEPHONE:
(562) 682-7027
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY:6CENSUS: 4DATE:
09/26/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Wilfreda Langa- Direct Support Professional (DSP)TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility staff mismanaged a resident's medication.
Facility spent residents P&I funds inappropriately.
Facility did not provide nutritious meals for resident.
Resident's dental care needs were not being met.
INVESTIGATION FINDINGS:
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**Please note: This report will supersede the original report dated: 9/11/23, to change information due to insufficient supporting evidence regarding the allegations occurred and to include additional client interviews. However, the findings of the allegations will remain the same: Unsubstantiated.**

Licensing Program Analyst (LPA) V. Maldonado made an unannounced subsequent visit at the facility for the purpose of completing the investigation regarding the above-mentioned allegations. LPA Maldonado met with Direct Support Professional (DSP), Wilfreda Langa, and explained the purpose for the visit.
On 09/23/2021, LPA Kruz Long made an initial complaint visit, which consisted of obtaining a copy of the Staff schedule/Client Roster and requested a copy of the Food Menu, Client #1's Facesheet, Physician's Report, Regional Center Meeting Records, Individual Program Plan, Preplacement Appraisal, Medications Record (MAR), Dental Appointment Records, Weight Chart and P & I Records to be faxed to LPA. LPA Long also conducted interviews with Staff# 1 (S1) and toured Client# 1's (C1) bedroom.
(Report Continued on LIC9099-C...)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023
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 6
Control Number 28-AS-20210915121120
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: ST. SHARBEL'S GARVEY
FACILITY NUMBER: 198603460
VISIT DATE: 09/26/2023
NARRATIVE
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On 09/11/23, LPA Maldonado obtained a copy of the staff schedule/client roster, and a copy of the documents initially requested by LPA Long, due to LPA Maldonado not being provided with them prior to the visit. Interviews were also held with Staff# 2 (S2), attempted interviews with Clients# 3-4 (C3-C4), and a telephonic interview was held with C1’s previous placement agency, Service Coordinator (SC). LPA was unable to interview C1 due to C1 no longer residing at the facility, and unable to interview C2 due to C2 being out in the community during the visit. A tour of the physical plant was also conducted with assistance of Administrator Peter Munzon, with special focus on C1’s old bedroom.
On 9/26/23, LPA Maldonado conducted telephonic interviews with C1 and C2 at their respective programs.

The investigation revealed the following:
Regarding allegation: Facility staff mismanaged a resident's medication.
It is alleged that when C1 went home for the weekend in July of 2021, C1's family received a call from the facility asking to check C1's medication bag, only to find C2's evening medication in C1's bag. Per interviews conducted with staff, (2) of (2) staff denied the allegations. S1 stated that C1's placement agency conducted their own investigation and did not find any discrepancies or issues with any of the client’s medications at the facility. Per interview with SC, the placement agency did investigate this allegation, however the placement agency did not provide the department with any information and/or evidence to support the allegation occurred. (4) of (4) clients could not corroborate the allegation. This allegation is Unsubstantiated.
Regarding allegation: Facility spent residents P&I funds inappropriately.
It is alleged that C1’s Personal and Incidental (P&I) funds were spent daily on Domino’s Pizza, for the months of July and August 2021. After review of C1’s P&I ledger and receipts, it was noted that funds were spent on Domino’s Pizza about two to three times per month for the entire year of 2021. P&I funds were also found to have been spent on other food purchases, clothing, an iPad, shoes, and a vacation fund. Per interviews conducted, (2) of (2) staff stated that S1 handles P&I for the clients and is only spent on what they want and/or need. Per S1 and SC, the vacation fund was approved by the placement agency. However, C1’s family did not approve of the vacation fund and the money was refunded to C1. S1 and SC also stated that the placement agency investigated this allegation and after review of the ledger and receipts, no discrepancies or issues were found. However, the placement agency did not provide the department with any information and/or evidence to support the allegation occurred. (4) of (4) clients could not corroborate the allegation. This allegation is unsubstantiated.

(Report Continued on LIC9099-C...)
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20210915121120
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: ST. SHARBEL'S GARVEY
FACILITY NUMBER: 198603460
VISIT DATE: 09/26/2023
NARRATIVE
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Regarding allegation: Facility did not provide nutritious meals for resident.
It is alleged that due to C1 eating Domino’s Pizza daily for two months, which is not nutritious, C1 developed and ulcer, a hernia, and several cavities. (2) of (2) staff interviewed stated that nutritious meals are cooked and provided to clients daily. S1 stated to be unaware of C1 developing any health conditions during C1’s stay at the facility. S1 and C1’s family would regularly take C1 to medical appointments. However, when C1’s family took C1 to the doctor, S1 was not provided information regarding the outcome of the appointments. Per C1's last IPP, dated: 10/28/2019, it is noted that C1 did have a cavity that required filling, however there is no indication that the facility was serving non-nutritious food, nor that this was the cause for the cavity. No medical records and/or other information was provided that would support the allegation. LPA Maldonado inspected the food supplies during the visit on 9/11/23 and observed a variety of perishable and non-perishable nutritious food such as cereals, fruits, vegetables, proteins, and was in sufficient amounts for clients currently in care. LPA Maldonado also observed (2) clients at the home during the visit to have lunch. Their lunch consisted of a sandwich, a soup with meat and vegetables, a side of fruit, and a cup of orange juice. (4) of (4) clients interviewed could not corroborate the allegation. This allegation is unsubstantiated.
Regarding allegation: Resident's dental care needs were not being met.
It is alleged that due to C1 not being provided nutritious foods at the facility, C1 developed cavities. (2) of (2) staff interviewed denied the allegations and stated that C1 was assisted brushing their teeth daily, as it was part of C1’s care plan. After review of C1's IPP, it has been noted that C1 requires prompts to complete steps in brushing C1's teeth and staff do hand-over-hand prompting and try to fade out after. Per S1, S1 and C1’s family were responsible for taking C1 to regular appointments. S1 is aware of C1 developing cavities while in care, but denied it being the fault of facility staff, although C1’s family blamed the facility. Per C1's last IPP, dated: 10/28/2019, it is noted that C1 did have a cavity that required filling, however there is no indication that the facility was serving non-nutritious food, nor that this was the cause for the cavity. S2 stated to have helped C1 directly with brushing and flossing C1’s teeth daily. Per C1’s IPP, Pre-Placement Appraisal, and Physician’s Report, it is noted that C1 did require the assistance with personal hygiene. Per C1’s IPP, C1’s needs were being met at the facility. Dental records provided indicate that C1 visited the dentist regularly. (4) of (4) clients could not corroborate the allegation. This allegation is Unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged. Therefore, the complaint investigation of the allegations are Unsubstantiated.
No Deficiencies were observed or cited under California Code of Regulations Title 22 during today's visit.
An exit interview was held with DSP, Wilfreda Langa, and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 28-AS-20210915121120
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: ST. SHARBEL'S GARVEY
FACILITY NUMBER: 198603460
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/29/2023
Section Cited
CCR
80072(a)(2)
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80072 Personal Rights
(a)...each client shall have personal rights which include..:(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment...
This requirement was not met as evidenced by:
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Licensee immediately fixed the bed mattress in question when observed to be wrong, and proceeded to purchase a new mattress altogether. This deficiency is cleared.
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Based on interviews conducted, the licensee failed to maintain comfortable accomodation/furnishing for (1) of (4) clients, when their bed was placed incorrectly, which poses a potential 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: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6