Inspection visit

complaintAugust 15, 2023

COGSWELL GARDEN HOMELicense 1976063478 citations on this visit

8 citations recorded

Inspector’s narrative

What the inspector wrote

Records (MARs) and interviewed the Current House Manager / Angelito Bajita. The investigation revealed the following; Allegations: Resident sustained pressure injuries while in care, Facility retained a resident with a prohibited health condition, Facility did not provide resident prompt medical treatment, and Facility did not maintain accurate resident’s records. During the course of this investigation, DS obtained and reviewed R1's medical records and facility file and conducted interviews with investigatory leads. The outcome of the investigation revealed that R1 was admitted to Los Angeles Community Hospital (LACH) on 3/3/21 and diagnosed with six pressure injuries in different wound areas, including some that were stage four. R1 was also observed thin and frail. Each pressure injury was identified as older and appeared to have developed prior to R1’s admission to LACH, on 3/3/21. Records from Outreach Home Health (OHH) (prepared by RN Maria Aguilar), show that as early as December 23, 2020, OHH noted a stage four pressure wound on R1's right buttock area. R1 was receiving wound care from OHH once per week. The facility did not maintain adequate records for R1. Client Notes prepared by staff dated 2/24/21, stated that “they told us to reposition him from time to time” but there was no documentation in R1's file regarding repositioning the resident. Staff interviewed stated that R1 was given a bath once every three days and staff only conducted body checks on R1 during bathing. Again, there was no documentation in R1's file regarding staff conducting body checks. Staff interviewed stated that logs were not kept for body checks or repositioning. Staff acknowledged not being aware that facility could not care for residents with stage three or four pressure injuries. Staff were not aware of the six pressure injuries R1 had developed during his stay at Cogswell Garden Home. This was likely due to lack of observation, documentation by facility staff and the lack of communication between staff, the treating physician and the Nurse from OHH. Staff acknowledged fault for lack of documentation and failing to seek timely medical care for R1. The former House Manager acknowledged of knowing the extent of R1's injury and failed to obtain medical treatment because he forgot. Based on the information gathered by DS, there is sufficient evidence to support the above allegations to be true. (See LIC 9099C for additional information) Allegation: Facility did not follow reporting requirements. During the course of this investigation, DS conducted an interview with the Administrator and the Administrator admitted that facility staff failed to report the hospitalization and pressure injuries involving R1 to Community Care Licensing (CCL). Based on the information gathered by DS, there is sufficient evidence to support this allegation to be true. Allegation: Facility staff are not properly trained. During the course of the investigation, DS conducted interviews with investigatory leads. Based on interviews conducted, the statements obtained were consistent and corroborated with the above-mentioned allegation. Staff and facility Registered Nurse (RN) / Nelia Aquino stated that there were no formal trainings conducted for Cogswell Garden Home staff to care and treat for the pressure injuries sustained on R1 and any other residents until after the incident involving R1. Staff acknowledged not being aware that facility could not care for residents with stage three or four pressure injuries due to lack of training. Based on the information gathered by DS, there is sufficient evidence to support this allegation to be true. Allegation: Facility did not follow Resident's care plan. During the course of this investigation, facility staff were unable to produce records showing that there was a care plan for the R1's pressure wound (right buttock area) and if staff were following the care plan. During today's visit, the Current House Manager looked in the file of R1 and was unable to produce a copy of a care plan for R1. Based on the information gathered, there is sufficient evidence to support this allegation to be true. Allegation: Staff are not administering medications to residents as prescribed. During today's visit, LPA Katrdzhyan reviewed a random selection of medications/Medication Administration Records (MARs) and discovered the following medication error. Thick-It Powder (PRN) for Resident 4 (R4) was missing at the facility. According to the Current House Manager, staff are administering Resident 5's (R5's) Thick-It Powder to R4 because R4's Thick-It Powder "ran out". Based on LPA's observation, interview conducted and record review, there is sufficient evidence to support this allegation to be true. Based on observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D. An immediate civil penalty will be issued today, in the amount of $500 due to Resident sustained pressure injuries while in care. At this time, an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 1569.49(e) & (f) and may be assessed at a later date. An exit interview was conducted and a copy of this report was provided along with the Appeals Rights.

Citations

8 citations recorded^*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

87211(a)(1)(B)Type B
Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.This requirement is not being met as evidenced by: Investigator / Dennis Sengconducted an interview with the Administrator and the Administrator admitted that facility staff failed to report the hospitalization and pressure injuries involving R1 to CCL. This poses a potential health, safety or personal rights risk to persons in care.
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87411(d)(1Type B
Personnel Requirements - General. All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance... This requirement is not being met as evidenced by: Staff and facility Registered Nurse (RN) / Nelia Aquino stated that there were no formal trainings conducted for Cogswell Garden Home staff to care and treat for the pressure injuries sustained on R1 and any other residents until after the incident involving R1. Staff acknowledged not being aware that facility could not care for residents with stage three or four pressure injuries due to lack of training. This poses a potential health, safety or personal rights risk to persons in care.
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87465(a)(2)Type A
Incidental Medical and Dental Care. The licensee shall provide assistance in meeting necessary medical and dental needs.This requirement is not being met as evidenced by: Records from Outreach Home Health (OHH) show that as early as 12/23/20, OHH noted a stage four pressure wound on R1's right buttock area but yet R1 continued to reside at the facility until being hospitalized on 3/3/21. This was likely due to lack of observation, documentation by facility staff and the lack of communication between staff, the treating physician and the Nurse from OHH. Staff acknowledged fault for failing to seek timely medical care for R1. The former House Manager acknowledged of knowing the extent of R1's injury and failed to obtain medical treatment because he forgot. This poses an immediate health, safety or personal rights risk to persons in care.
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87465(c)(2)Type A
Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement is not being met as evidenced by:On 8/15/23, LPA reviewed medications/Medication Administration Record (MAR) for Resident 4 (R4) and discovered that the Thick-It Powder (PRN) for R4 was missing at the facility. According to the Current House Manager, staff are administering Resident 5's (R5's) Thick-It Powder to R4 because R4's Thick-It Powder "ran out". This poses an immediate health, safety or personal rights risk to persons in care.
87506(b)(13)Type B
Resident Records. Each resident’s record shall contain at least the following information:Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or needed services. This requirement is not being met as evidenced by: R1 was receiving wound care from OHH once per week. The facility did not maintain adequate records for R1. Client Notes prepared by staff dated 2/24/21, stated that “they told us to reposition him from time to time” but there was no documentation in R1's file regarding repositioning the resident. Staff interviewed stated that R1 was given a bath once every three days and staff only conducted body checks on R1 during bathing. Again, there was no documentation in R1's file regarding staff conducting body checks. Staff interviewed stated that logs were not kept for body checks or repositioning. This poses a potential health, safety or personal rights risk to persons in care.
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87609(b)(2)Type A
Allowable Health Conditions and the Use of Home Health Agencies. Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: The licensee provides the supporting care and supervision needed to meet the needs of the resident receiving home health care. This requirement is not being met as evidenced by: R1 was admitted to Los Angeles Community Hospital on 3/3/21 and diagnosed with six pressure injuries in different wound areas, including some that were stage four. Each pressure injury was identified as older and appeared to have developed prior to R1’s admission to LACH, on 3/3/21. Records from Outreach Home Health (OHH) show that as early as December 23, 2020, OHH noted a stage four pressure wound on R1's right buttock area. This poses an immediate health, safety or personal rights risk to persons in care.
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87611(b)(1)(AType B
General Requirements for Allowable Health Conditions. The licensee shall complete and maintain a current, written record of care for each resident that includes, but is not limited to, the following: Documentation from the physician of the following: (A) Stability of the medical condition(s); (B) Medical condition(s) which require incidental medical services; (C) Method of intervention; (D) Resident's ability to perform the procedure; and (E) An appropriately skilled professional shall be identified who will perform the procedure if the resident needs assistance. This requirement is not being met as evidenced by: During the course of this investigation, facility staff were unable to produce records showing that there was a care plan for the R1's pressure wound (right buttock area) and if staff were following the care plan. On 8/15/23, the Current House Manager looked in the file of R1 and was unable to produce a copy of a care plan for R1. This poses a potential health, safety or personal rights risk to persons in care.
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87615(a)(1)Type A
Prohibited Health Conditions. Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Stage 3 and 4 pressure injuries. This requirement is not being met as evidenced by: Records from Outreach Home Health (OHH) show that as early as 12/23/20, OHH noted a stage four pressure wound on R1's right buttock area but yet R1 continued to reside at the facility until being hospitalized on 3/3/21. The former House Manager acknowledged of knowing the extent of R1's injury and failed to obtain medical treatment because he forgot. This poses an immediate health, safety or personal rights risk to persons in care.

FAQ · About this visit

Common questions about this visit

What happened during the August 15, 2023 inspection of COGSWELL GARDEN HOME?

This was a complaint inspection of COGSWELL GARDEN HOME on August 15, 2023. 8 citations were issued: 4 Type A (serious) and 4 Type B.

Were any citations issued to COGSWELL GARDEN HOME on August 15, 2023?

Yes, 8 citations were issued (4 Type A, 4 Type B). The first citation was for: "Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for t..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLD View original report

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Data from CCLD public records. Last updated May 25, 2026. If you believe any information is inaccurate, report it here.

complaint·August 15, 2023