Cogswell Garden Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced required annual visit. LPA was greeted by staff and reason for the visit was explained. Administrator was notified but unable to attend. The facility is licensed to serve (15) elderly residents of which four (4) may be non-ambulatory, two non-ambulatory each in rooms 1 and 8. The facility is a single-story home located in a residential area of El Monte. The home consists of (8) resident bedrooms, one (1) staff room/office, (3) resident bathrooms, a living room, a dining area, a kitchen, a laundry room, a front yard, and a backyard. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: The front and backyard are well maintained. There is a covered patio in the front yard with sufficient seating. Passageways and exits are free of obstruction. The water temperature was tested in the bathrooms and measured within the required 105 degrees F - 120 degrees F. LPA observed grab bars and non-skid mats in showers. Combination smoke/carbon monoxide detectors were observed by the kitchen and in the hallway, were tested and are operable. There were fire extinguishers throughout the home. Last emergency drill was conducted April 2026. continued on LIC809C Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in a kitchen cabinet and are inaccessible to residents. Cleaning supplies and disinfectants are locked in a cabinet outside and are inaccessible to the residents. Sufficient supply of 2 days perishable and 7 days non-perishable foods were observed. Dining area and living room were observed to be clean and free of obstructions and have sufficient seating for residents in care. Medications are centrally stored in a locked hall closet. Medications are documented properly and given as prescribed. Resident bedrooms were observed to contain the required furniture which includes, for each resident, a bed, a chair, night stand, a lamp, or lights sufficient for reading. Bed linens were clean and in good repair. There is closet space for clothing and other belongings. Hall closet contained extra, clean linens. LPA reviewed (7) resident files. 6 out of 7 files were observed to contain required documentation. Facility file for R1 did not contain a medical assessment for review. Deficiency cited. LPA reviewed four (4) staff files. Staff files were observed to contain required documentation including personnel record, fingerprint clearance, health screening with TB clearance, CPR/First aid certificate and continued education in-service trainings. Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during today’s visit were documented on the attached LIC809D. Exit interview held and a copy of this report, LIC809D and appeal rights were provided to Arni Castillo, Staff.the state’s words, verbatim · CDSS document, Aug 13, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Staff Raymond DeGuzman and explained the reason for the visit. The purpose of the visit is to complete the required inspection. LPA Trueman toured the facility along with Staff Raymond DeGuzman today 08/05/202 at 12:40 PM and the following was observed: Facility contains 8 Resident Bedrooms and 4 Resident Bathrooms, dining room, living room, TV room, and laundry room. Required Annual Inspection included Infection Control, Operational Requirements, Physical Plant/ Environmental Safety, Staffing, Personnel Records/ Staff Training, Resident Rights- Information, Planned Activities, Food Service, Incidental Medical and Dental, Resident Records/ Incident Reports, Disaster preparedness, and Residents with Special Health Needs. LPA observed sufficient supply of 2 day perishables and 7 day non perishables. All staff were cleared and associated. Visitation signage was posted along with signage for hand washing and proper sanitizing. Licensee maintained an individual admission agreement for each client. Fire Clearance has been maintained. Carbon monoxide detector was observed in the facility. Each client has personal rights free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature. Facility was clean, safe, sanitary, and in good repair at all times for the safety and well being of clients, employees and visitors. Medication was reviewed for 3 residents and was given per physician's directions. 3 Client Files and 4 Staff Files were reviewed. Interviews were conducted with 2 Staff. Clients were at Day Program at time of the visit today. No deficiencies. Exit interview conducted.the state’s words, verbatim · CDSS document, Aug 5, 2025

Allegation investigated: Resident sustained multiple unexplained fractures Staff did not seek timely medical attention for resident Staff did not notify resident's authorized representative of resident's fractures Staff did not follow resident(s) diet as prescribed by a physician

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Staff S1 and explained the reason for the visit. The purpose of the visit is to deliver findings from the original complaint dated 01/21/2025. Shortly thereafter Administrator Lilian Salmorin arrived. The initial visit was a Health and Safety Check conducted on 01/21/2025 and included the following: LPA reviewed Resident R1's file and facility to submit Emergency Face Sheet, Admission Agreement, Individual Program Plan (IPP), Special Incident Reports (SIR"s), Physician's Report, Hospital Documentation, and Nursing Care Plan, LPA conducted a tour of the facility inside and out with Staff S1 and observed clients in the facility at the time of the visit. Facility had sufficient 2 day supply of perishables and 7 days supply of non- perishables and the water temperature measured between 105 F. and 120 F.both meeting Title 22 Regulations. LPA observed the clients to identify any signs of neglect, abuse or other immediate Health and Safety threats. LPA did not observe any immediate Health & Safety concerns during the visit. Unsubstantiated At today's visit interview was conducted with Administrator Lilian Salmorin and Staff S1. Investigation was conducted by the Investigations Branch (IB) and completed 03/19/2025 for allegations Resident sustained multiple unexplained fractures and Staff did not seek timely medical attention for resident. Investigation consisted of interviews with facility staff, residents, review of medical documentation and Special Incident Reports (SIR's) from San Gabriel Pomona Regional Center and from Cogswell Garden Home. Photograph of Resident R1 taken on 11/08/2023 was observed and file was reviewed. In regards to the allegation Resident sustained multiple unexplained fractures based on interviews conducted and information gathered Investigation was completed by Investigations Branch (IB) Investigator Christine Ferris on 03/19/2025 it was revealed that Staff denied Resident R1 had any falls or sustained any injuries at the facility. Mainstream Day Program Administrator reported Resident R1 has fallen while attending day program but did not sustain any injuries. Per family member of Resident R1, Resident R1 has not disclosed any falls to her and was recently diagnosed with osteopenia and then osteoporosis. Per San Gabriel/Pomona Regional Center Case Manager and reports provided, Resident R1 sustained a rib fracture and foot fracture prior to residing at the facility and the facility has been communicative regarding any falls or injuries, yet there have been no reports of Resident R1 falling or sustaining any injuries. Resident R1 was unable to provide a meaningful statement, and clients did not report any concerns. Per Kaiser Permanente Baldwin Park medical records, the fractures found were age indeterminable and suspected as being old. There was no evidence to indicate Resident R1 sustained his injuries at the facility, therefore, the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove alleged violation did or did not occur, therefore the above allegation is Unsubstantiated. In regards to the allegation Staff did not seek timely medical attention for resident, Investigation was completed by Investigations Branch (IB) Investigator Christine Ferris on 03/19/2025 it was revealed that the investigation did not provide sufficient evidence to substantiate neglect/lack of care in not seeking timely medical attention. Staff denied Resident R1 had any falls or sustained any injuries at the facility, thus, no medical attention was needed. Therefore, the allegation is unsubstantiated. Day Program interview with the Administrator stated that on 01/08/25 Resident R1 was pushed off his chair and has known Resident R1 40 years and he has not complained about falling at home or being at home. Residents interviewed had not witnessed any falls at the home. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove alleged violation did or did not occur, therefore the above allegation is Unsubstantiated. In regards to the allegation Staff did not notify Resident R1's authorized representative of resident's fractures it was determined by the Investigator in IB Investigation that residents, and staff had never observed a fall at the home and Day Program Administrator stated resident had fallen when pushed off his chair. Interview with Administrator at Cogswell who stated that Resident R1 had never fallen at the facility so therefore there was not anything to report to the authorized representative. Interview with Staff S1 who stated they did not report anything to Resident R1's authorized representative because there was nothing to report. Stated they have in the past always notified the authorized representative. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove alleged violation did or did not occur, therefore the above allegation is Unsubstantiated. In regards to the allegation Staff did not follow residents diet as prescribed by a physician, based on interviews conducted and information gathered it was revealed by Administrator Lilian Salmorin that every 3 months Resident R1 goes to the PKU specialist at UCLA. Documentation from Kaiser UCLA was observed dated 03/03/2025 which showed Resident R1's blood work related to PKU. Dietician at UCLA recommended juice formula and no medication for PKU. Administrator stated there is a diet just for him and it is posted on the refrigerator and the LPA observed it at today's visit. File for Resident R1 revealed documents for meat and meat substitutes, low protein, low-fat milk, fruits and berries. Interview with Staff S1 who stated that the PKU diet is followed for Resident R1. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove alleged violation did or did not occur, therefore the above allegation is Unsubstantiated.the state’s words, verbatim · CDSS document, Apr 3, 2025 · control 28-AS-20250121144952

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Noemi Galarza made unannounced case management visit regarding a self reported incident on the relocation of 2 residents from Bedell Family Crest, The # 197601322, 3267 Fair Oaks, Altadena, CA 91001 to Cogswell Garden Home due to mandatory evacuation orders from Fire Advisory. LPA met with Administrator Lilian Salmorin and explained the purpose of the visit. A physical plant tour of the facility was conducted to check the health and safety of the 2 evacuee residents. The following observations were made: Both relocated residents have designated rooms with beds, bedding/linen, and hygiene supplies. Residents are in need of more clothing. Residents do not use medical equipment and are ambulatory. Medication Administration Records (MARs) for R1 only, medications, resident file documents were reviewed. One (1) additional staff was hired to accommodate the increase in resident census. Residents were transferred without medical insurance information and Face Sheet/Emergency Information. Regional Center has been notified. Review of staff rosters indicate there is sufficient staffing available to provide care for residents of both facilities. The facility has sufficient 2-day perishable and 7-day non perishable food supplies. The facility dining room is able to accommodate all residents. The last routine fire inspection was conducted 12/19/2024. The last fire drill was conducted on 12/20/2024. Administrator stated that it is unknown whether residents have responsible parties, and/or if they were notified. Exit interview was conducted with Administrator Lilian Salmorin and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jan 16, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Staff Arnie Castillo and explained the reason for the visit. Shortly thereafter Administrator Lilian Salmorin arrived. The purpose of the visit is to complete the required inspection. LPA Trueman toured the facility along with Staff Arnie Castillo today 09/05/2024 at 11:50 AM and the following was observed: Facility contains 8 Resident Bedrooms and 4 Resident Bathrooms, dining room, living room, TV room, and laundry room. Required Annual Inspection included Infection Control, Operational Requirements, Physical Plant/ Environmental Safety, Staffing, Personnel Records/ Staff Training, Resident Rights- Information, Planned Activities, Food Service, Incidental Medical and Dental, Resident Records/ Incident Reports, Disaster preparedness, and Residents with Special Health Needs. LPA observed sufficient supply of 2 day perishables and 7 day non perishables. All staff were cleared and associated. Visitation signage was posted along with signage for hand washing and proper sanitizing. Licensee maintained an individual admission agreement for each client. Fire Clearance has been maintained. Carbon monoxide detector was observed in the facility. Each client has personal rights free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature. Facility was clean, safe, sanitary, and in good repair at all times for the safety and well being of clients, employees and visitors. Medication was reviewed for 3 residents and was given per physician's directions. 4 Client Files and 5 Staff Files were reviewed. Interviews were conducted with 3 Staff and 3 residents. No deficiencies. Exit interview conducted.the state’s words, verbatim · CDSS document, Sep 5, 2024

Allegation investigated: Staff does not ensure facility water heater is in good repair Staff does not ensure facility has hot water for clients in care

Licensing Program Analyst (LPA), Glenn Trueman, made a visit to Cogswell Garden Home. The purpose of today's visit is to investigate the allegations above. On today's visit LPA met with and interviewed Staff S1 and Staff S2 from 1:20 PM to 145 PM At today's visit staff and resident roster was submitted. Interview was conducted telephonically with Administrator Lillian Salmorin at 1:50 PM. Interview was conducted with Client C1- C4 from 1:55 PM to 2:45 PM. In regards to the allegation Staff does not ensure facility water heater is in good repair, based on interviews conducted and information gathered it was revealed in interviews with staff that a new water heater was installed after 1 day of no hot water. New heater was installed within 24 hours. Interviews with Clients C1- C4 who all stated that there was new heater installed within 1 day. Interview with Regional Center Representative who stated that the water heater was replaced within 24 hours. It should be noted that the San Gabriel Pomona Regional Center's result of their investigation was Unsubstantiated. Unsubstantiated Interview was conducted with the Administrator Lillian Salmorin who stated that the new maintenance man said the water heater was no longer repairable. Stated she gave approval for him to purchase a new one and that he installed it within 24 hours. LPA observed the new water heater which had a piece of masking tape and on it stating 05/01/2024 replaced. Documentation from San Gabriel Pomona Regional Center states that Client C1 informed the Service Coordinator that they were offered another shower that has a different heater, but refused. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove alleged violation did or did not occur, therefore the above allegation is Unsubstantiated. In regards to the allegation, Staff does not ensure facility has hot water for clients in care, based on interviews conducted and information gathered it was revealed by Regional Center Representative who stated that facility was without hot water for 1 day and Client C1 was offered to shower with hot water in another shower, but refused. Interview with Staff who stated that there was no hot water for 1 day and the water heater was replaced within 24 hours. At today's visit hot water temperature measured at 105F. in 2 shower rooms. Interview conducted with Client C2 - C4 who stated that there was no hot water for 1 day and within a day the new water heater was installed. It should be noted that the San Gabriel Pomona Regional Center's result of their investigation was Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove alleged violation did or did not occur, therefore the above allegation is Unsubstantiated.the state’s words, verbatim · CDSS document, May 9, 2024 · control 28-AS-20240501155416

Allegation investigated: Staff did not follow PKU diet orders for residents Staff did not implement the IPP for residents Administrator did not assess the needs of residents prior to placement.

The reason for this report is to change the findings delivered on 02/29/24. LPA inadvertently listed the allegations as Unsubstaniated and they should be Substantiated. The reason for today's visit 02/29/24 is to correct the citation issued on 1/30/24 and issue an additional citation to address the remaining allegations. Licensing Program Analyst (LPA), Glenn Trueman, made a visit to Cogswell Garden Home. The purpose of today's visit is to investigate the allegations above. On today's visit LPA met with Staff Arni Castillo. LPA received a Corrective Action Plan report from the SG/Pomona Regional Center dated January 22, 2024. The report states that the facility was unaware Client's C1 and C 2 were on a PKU diet and did not know what it was and needed to be on a special diet. This information was included in the IPP Risk Section for the reports written for 2016, 2019 and 2022. At today's visit staff and resident roster was submitted. Interview was conducted telephonically with Administrator Lillian Salmorin at 1:45 PM. Interview was conducted with Staff S 1 at 2:00 PM. Substantiated Interview was conducted with Client C1 at 2:45 PM. Client C 2 was in the hospital. In regards to the allegation Staff did not follow PKU diet orders for residents, based on interviews conducted and information gathered the Administrator stated that it is true that they did not follow PKU diet orders and was unaware of it. Staff S 1 stated that it was true that they were unaware of a PKU diet, but once Regional Center told them they implemented it. Interview with Client C 1 who stated he gets all his meals and is aware that he needs to be on a PKU diet. It should be noted that San Gabriel Pomona Regional Center on Corrective Action Plan 01/22/24 had substantiated findings. Review of files for C1 and C2 noted that they have PKU and needed to be on a special diet. In regards to the allegation Staff did not implement the IPP for residents, based on interviews conducted and information gathered, Administrator stated that she did not implement what was in the Initial Program Plan (IPP) in which the information was included in the IPP Risk Section for the reports written for 2016, 2019 and 2022. Interview with Staff S 1 who confirmed that they did not implement what was in Client C1 and C2's Initial Program Plan (IPP). It should be noted that San Gabriel Pomona Regional Center Corrective Action Plan 01/22/24 had substantiated findings. In regards to the allegation Administrator did not assess the needs of residents prior to placement, based on interviews conducted and information gathered Administrator stated that she had failed to review 2016 IPP prior to placement for C1 and C2. Interview with Staff S 1 who confirmed that the IPP was not reviewed for Client's C 1 and C 2 prior to placement. Interview with Client C 1 who stated he is on a PKU diet per doctor's orders. It should be noted that San Gabriel Pomona Regional Center on Corrective Action Plan 01/22/24 had substantiated findings. Based on observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the allegations Staff did not follow PKU diet orders for residents, Staff did not implement the IPP for residents, and Administrator did not assess the needs of residents prior to placement. are found to be Substantiated. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, Mar 4, 2024 · control 28-AS-20240123083006

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(7) · Plan of correction due date: Feb 2, 2024

General Food Service Requirements (b) The following food service requirements shall apply: Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement was not met as evidenced by: Review of Corrective Action Plan, and interviews conducted the facility did not follow a PKU diet, did not implement IPP and did not review IPP prior to placement for C 1 and C 2 which poses a potential health and safety risk for clients in care.the state’s words, verbatim · CDSS document, Mar 4, 2024

Plan of correction: Administrator will conduct training for all staff which covers reviewing IPP's and reviewing PKU diets. Log of those who attended will be submitted to Licensing by POC due date. Deficiency cleared on 02/02/24 Facility complied

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87457(c)(4) · Plan of correction due date: Mar 4, 2024

Pre-Admission Appraisal - General Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. If a needs assessment has already been completed by a placement agency or consultant, this shall be obtained and included in the facility's appraisal. This requirement was not met as evidenced by: The facility did not implement the IPP and did not complete a pre admission appraisal that contains the required information which poses a potential health and safety risk for clients in care.the state’s words, verbatim · CDSS document, Mar 4, 2024

Plan of correction: Facility complied with the IPP and did complete a pre admission appraisal that contains the required information by POC due date. Administrator complied with Corrective Action Plan on 02/22/24 from Regional Center which included the above requirements. Deficiency cleared.

Allegation investigated: Staff did not follow PKU diet orders for residents Staff did not implement the IPP for residents Administrator did not assess the needs of residents prior to placement.

The reason for today's visit 02/29/24 is to correct the citation issued on 1/30/24 and issue an additional citation to address the remaining allegations. Licensing Program Analyst (LPA), Glenn Trueman, made a visit to Cogswell Garden Home. The purpose of today's visit is to investigate the allegations above. On today's visit LPA met with Staff Arni Castillo. LPA received a Corrective Action Plan report from the SG/Pomona Regional Center dated January 22, 2024. The report states that the facility was unaware Client's C1 and C 2 were on a PKU diet and did not know what it was and needed to be on a special diet. This information was included in the IPP Risk Section for the reports written for 2016, 2019 and 2022. At today's visit staff and resident roster was submitted. Interview was conducted telephonically with Administrator Lillian Salmorin at 1:45 PM. Interview was conducted with Staff S 1 at 2:00 PM. Interview was conducted with Client C1 at 2:45 PM. Client C 2 was in the hospital. In regards to the allegation Staff did not follow PKU diet orders for residents, based on interviews Unsubstantiated conducted and information gathered the Administrator stated that it is true that they did not follow PKU diet orders and was unaware of it. Staff S 1 stated that it was true that they were unaware of a PKU diet, but once Regional Center told them they implemented it. Interview with Client C 1 who stated he gets all his meals and is aware that he needs to be on a PKU diet. It should be noted that San Gabriel Pomona Regional Center on Corrective Action Plan 01/22/24 had substantiated findings. Review of files for C1 and C2 noted that they have PKU and needed to be on a special diet. In regards to the allegation Staff did not implement the IPP for residents, based on interviews conducted and information gathered, Administrator stated that she did not implement what was in the Initial Program Plan (IPP) in which the information was included in the IPP Risk Section for the reports written for 2016, 2019 and 2022. Interview with Staff S 1 who confirmed that they did not implement what was in Client C1 and C2's Initial Program Plan (IPP). It should be noted that San Gabriel Pomona Regional Center Corrective Action Plan 01/22/24 had substantiated findings. In regards to the allegation Administrator did not assess the needs of residents prior to placement, based on interviews conducted and information gathered Administrator stated that she had failed to review 2016 IPP prior to placement for C1 and C2. Interview with Staff S 1 who confirmed that the IPP was not reviewed for Client's C 1 and C 2 prior to placement. Interview with Client C 1 who stated he is on a PKU diet per doctor's orders. It should be noted that San Gabriel Pomona Regional Center on Corrective Action Plan 01/22/24 had substantiated findings. Based on observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the allegations Staff did not follow PKU diet orders for residents, Staff did not implement the IPP for residents, and Administrator did not assess the needs of residents prior to placement. are found to be Substantiated. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, Feb 29, 2024 · control 28-AS-20240123083006

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(7) · Plan of correction due date: Feb 2, 2024

General Food Service Requirements (b) The following food service requirements shall apply: Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement was not met as evidenced by: Review of Corrective Action Plan, and interviews conducted the facility did not follow a PKU diet, did not implement IPP and did not review IPP prior to placement for C 1 and C 2 which poses a potential health and safety risk for clients in care.the state’s words, verbatim · CDSS document, Feb 29, 2024

Plan of correction: Administrator will conduct training for all staff which covers reviewing IPP's and reviewing PKU diets. Log of those who attended will be submitted to Licensing by POC due date. Deficiency cleared on 02/02/24 Facility complied

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87457(c)(4) · Plan of correction due date: Mar 4, 2024

Pre-Admission Appraisal - General Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. If a needs assessment has already been completed by a placement agency or consultant, this shall be obtained and included in the facility's appraisal. This requirement was not met as evidenced by: The facility did not implement the IPP and did not complete a pre admission appraisal that contains the required information which poses a potential health and safety risk for clients in care.the state’s words, verbatim · CDSS document, Feb 29, 2024

Plan of correction: Facility complied with the IPP and did complete a pre admission appraisal that contains the required information by POC due date. Administrator complied with Corrective Action Plan on 02/22/24 from Regional Center which included the above requirements. Deficiency cleared.

Allegation investigated: Staff did not follow PKU diet orders for residents Staff did not implement the IPP for residents Administrator did not assess the needs of residents prior to placement.

Licensing Program Analyst (LPA), Glenn Trueman, made a visit to Cogswell Garden Home. The purpose of today's visit is to investigate the allegations above. On today's visit LPA met with Staff Arni Castillo. LPA received a Corrective Action Plan report from the SG/Pomona Regional Center dated January 22, 2024. The report states that the facility was unaware Client's C1 and C 2 were on a PKU diet and did not know what it was and needed to be on a special diet. This information was included in the IPP Risk Section for the reports written for 2016, 2019 and 2022. At today's visit staff and resident roster was submitted. Interview was conducted telephonically with Administrator Lillian Salmorin at 1:45 PM. Interview was conducted with Staff S 1 at 2:00 PM. Interview was conducted with Client C1 at 2:45 PM. Client C 2 was in the hospital. In regards to the allegation Staff did not follow PKU diet orders for residents, based on interviews conducted and information gathered the Administrator stated that it is true that they did not follow PKU diet orders and was unaware of it. Staff S 1 stated that it was true that they were unaware Substantiated of a PKU diet, but once Regional Center told them they implemented it. Interview with Client C 1 who stated he gets all his meals and is aware that he needs to be on a PKU diet. It should be noted that San Gabriel Pomona Regional Center on Corrective Action Plan 01/22/24 had substantiated findings. Review of files for C1 and C2 noted that they have PKU and needed to be on a special diet. In regards to the allegation Staff did not implement the IPP for residents, based on interviews conducted and information gathered, Administrator stated that she did not implement what was in the Initial Program Plan (IPP) in which the information was included in the IPP Risk Section for the reports written for 2016, 2019 and 2022. Interview with Staff S 1 who confirmed that they did not implement what was in Client C1 and C2's Initial Program Plan (IPP). It should be noted that San Gabriel Pomona Regional Center Corrective Action Plan 01/22/24 had substantiated findings. In regards to the allegation Administrator did not assess the needs of residents prior to placement, based on interviews conducted and information gathered Administrator stated that she had failed to review 2016 IPP prior to placement for C1 and C2. Interview with Staff S 1 who confirmed that the IPP was not reviewed for Client's C 1 and C 2 prior to placement. Interview with Client C 1 who stated he is on a PKU diet per doctor's orders. It should be noted that San Gabriel Pomona Regional Center on Corrective Action Plan 01/22/24 had substantiated findings. Based on observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the allegations Staff did not follow PKU diet orders for residents, Staff did not implement the IPP for residents, and Administrator did not assess the needs of residents prior to placement. are found to be Substantiated. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, Jan 30, 2024 · control 28-AS-20240123083006

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Feb 2, 2024

Personal Rights of Residents in All Facilities Residents in all residential care facilities for the elderly shall have all of the following personal rights: to be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: review of Corrective Action Plan, and interviews conducted the facility did not follow a PKU diet, did not implement IPP and did not review IPP prior to placement for C 1 and C 2 which poses a potential health and safety risk for clients in care.the state’s words, verbatim · CDSS document, Jan 30, 2024

Plan of correction: Administrator will conduct training for all staff which covers reviewing IPP's and reviewing PKU diets. Log of those who attended will be submitted to Licensing by POC due date.