<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 03/28/2023
Date Signed: 03/28/2023 04:45:17 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
09/14/2021 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210914122257
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: 165DATE:
03/28/2023
UNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Administrator Yitzi TeichmanTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident hit by another resident in care resulting in an injury.
Resident hit by another resident in care.
Staff are not providing residents with food of good quality.
Facility air conditioner is in disrepair.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent complaint investigation visit for the allegation above. LPA met with Administrator Yitzi Teichman and the purpose of the visit was discussed.

Initial visit conducted on 9/16/21 consisted of the following: LPA obtained a copy of the staff and client rosters, conducted a tour of the physical plant, observed the food supply, and interviewed the Staff #1-#3 (S1-S3) and collected Facesheets and any incident reports regarding clients #1-#4 (C1-C4).

On Todays visit LPA interviewed clients #1-12 (C1-C12) and Staff #4-6 (S4-S6). Clients #13 (C13) was not available for interview. The investigation revealed the following:

In regards to the allegation "Resident hit by another resident in care resulting in an injury." it was alleged that C3 hit C4 resulting in an injury and C13 hit C5 also resulting in an injury and staff did not do anything about it..........

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: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023
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 3
Control Number 28-AS-20210914122257
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: 03/28/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 (6) of (6) Staff interviewed denied the allegation. (11) of (12) Clients interviewed could not corroborate the allegation. File review showed that the incident between C3 and C4 was on 5/4/21 where C4 refused medical attention and C3 was put on hold by local law enforcement. During this incident, it was the facility staff that separated the clients in care and called 9-1-1. C3 denied the incident and C4 stated that they were not injured. File review did not show an incident between C13 and C5. Interviews did not show that C13 hit C5 resulting in an injury. Interviews show that when staff are aware of incidents between clients, they address them as soon as they are aware of them and are not ignored. Based on the interviews and files reviewed; 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 allegation "Resident hit by another resident in care" it is alleged that C2 hit C1 and staff did not do anything about it. (6) of (6) Staff interviewed denied the allegation. (11) of (12) Clients interviewed could not corroborate the allegation. C2 denied ever hitting C1. Interviews show that there was a day when C2 did hit C1 in the hallway of the facility. Staff were not present in the moment but observed the incident via camera and immediately intervened to separate the clients. 911 was called and C2 was placed in a 51-50 hold. Interviews stated that staff arrived as quickly as possible and assisted C1. File review confirms incident to have occurred on 3/28/21. Files reviewed and interviews show that C1 denied medical attention and refused to press charges on C2. Interviews and files reviewed show staff addressing the issue immediately at the time of incident. No other incidents involving C1 and C2 were observed on file. Based on the interviews and files reviewed; 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 allegation "Staff are not providing residents with food of good quality" it was alleged that the facility serves rotten food and cold meals. (6) of (6) Staff interviewed denied the allegation. (11) of (12) Clients interviewed could not corroborate the allegation. Interviews do not show that the facility has served clients rotten food and cold meals. LPA toured the physical plant during both visits and did not observe rotten or expired food in the kitchen. LPA was not provided proof of rotten meals being served to clients in care. Client interviews did not show that the food was bad but that clients did want menu changes. Based on the interviews conducted and observations; 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

Continued on LIC 9099-C
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20210914122257
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: 03/28/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
In regards to the allegation "Facility air conditioner is in disrepair" it was alleged that the facility air conditioner (AC) is broken. (6) of (6) Staff interviewed denied the allegation. (11) of (12) Clients interviewed could not corroborate the allegation. LPA did not observe the AC broken during the initial visit. LPA was not provided with a date of when the AC would have been broken. File review did not show maintenance reports or bill statements of AC repairs for the times of August 2021-September 2021. Based on the interviews conducted and observations; 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: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3