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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 12/27/2022
Date Signed: 12/27/2022 11:52:19 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
12/30/2020 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20201230115829
FACILITY NAME:PICO RIVERA GARDENSFACILITY NUMBER:
198600539
ADMINISTRATOR:DOMINGUEZ, SANTOSFACILITY TYPE:
735
ADDRESS:6525 ROSEMEAD BLVD.TELEPHONE:
(562) 949-8489
CITY:PICO RIVERASTATE: CAZIP CODE:
90660
CAPACITY:185CENSUS: 168DATE:
12/27/2022
UNANNOUNCEDTIME BEGAN:
08:33 AM
MET WITH:Administrator Assistant Andrew DeVeraTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Lack of supervision resulting in a resident harassing another resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted, a subsequent complaint visit to investigate the allegations listed above. LPA Gonzalez conducted initial visit on 01-02-2021.

The investigation consisted of the following: Copy of staff and resident roster was obtained, Daily Communication Log, eight (8) residents were interviewed, five (5) staff were interviewed, tour of facility grounds was conducted at 11:25 AM.
The investigation revealed the following regarding lack of supervision resulting in a resident harassing another resident in care:
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2022
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-20201230115829
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PICO RIVERA GARDENS
FACILITY NUMBER: 198600539
VISIT DATE: 12/27/2022
NARRATIVE
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Eight (8) out of nine (9) clients confirmed witnessing other clients verbal argue and/or physically assault other clients; witnessed staff immediately intervene to de-escalate the situation. Five (5) out of the five staff interviewed deny the allegation of not supervising clients, which results in clients harassing other clients, however, they confirm witnessing verbal and/or physical altercations between clients. Staff allege they immediately intervene when they have observed clients verbally fighting and redirect clients. Staff #1 (S1) alleges a log of communication is kept of all activities that occur at the facility. Client #1 (C1) confirmed that staff does keep track of incidents and that most are verbal fights. Client # 5 (C5) alleges to have seen clients verbally argue and he/or she reports it to staff and they immediately come to help because they don’t want people fighting.

LPA reviewed the Daily Communication Log for 12/25/22 to 12/26/2022 which showed various updates of clients behaviors or other incidents that were observed by staff at the facility.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2