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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 11/29/2022
Date Signed: 11/29/2022 04:23:35 PM

Unsubstantiated


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
11/28/2022 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221128091330
FACILITY NAME:PICO RIVERA GARDENSFACILITY NUMBER:
198600539
ADMINISTRATOR:MEIR SHAUL YITZI TEICHMANFACILITY TYPE:
735
ADDRESS:6525 ROSEMEAD BLVD.TELEPHONE:
(562) 949-8489
CITY:PICO RIVERASTATE: CAZIP CODE:
90660
CAPACITY:185CENSUS: 170DATE:
11/29/2022
UNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:Administrator Yitzi TeichmanTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Staff put medication in the pancakes
Staff gave resident wrong medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced complaint visit for the allegation above. LPA met with Administrator Yitzi Teichman and the purpose of the visit was discussed.

The following was conducted on todays visit, LPA interviewed Staff #1-#7 (S1-S7) and Clients #1-#16 (C1-C16). LPA toured the physical plant. LPA collected and reviewed documents from C1 file as well as the facility staff roster and client roster.

The investigation revealed the following: In regards to the allegations "Staff put medication in the pancakes" it was alleged that the facility staff mixed medications into the pancakes served to clients. (7) of (7) Staff interviewed denied the allegation. (15) of (16 ) clients interviewed could not corroborate the allegation. LPA was not provided with any proof that staff put medications into client meals. Staff interviewed denied medication ever given to clients without their consent.

Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
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 2
Control Number 28-AS-20221128091330
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: PICO RIVERA GARDENS
FACILITY NUMBER: 198600539
VISIT DATE: 11/29/2022
NARRATIVE
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 Review of the food menu shows that pancakes are served on Monday mornings. S2 is the staff that cooks and is on shift on those days. S2 denies that any medication is ever placed in client meals. Based on the interviews and observations conducted there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

In regards to the allegations "Staff gave resident wrong medication" it was alleged C1 was given the wrong medication. (7) of (7) Staff interviewed denied the allegation. (15) of (16 ) clients interviewed could not corroborate the allegation. LPA was not provided a date of when the incident occurred. C1 stated to remember the incident happening but not the date. C1 stated they took the medicine and did not notify staff. LPA reviewed C1's medication record and did not observe medication error notes. Based on the interviews conducted and files reviewed there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit Interview conducted and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2