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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 05/30/2023
Date Signed: 05/30/2023 03:49:18 PM

Substantiated


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
05/24/2023 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230524084358
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: 160DATE:
05/30/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Staff Andrew De VeraTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff do not report incidents involving resident as necessary.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced initial complaint visit for the allegation above. LPA met with Staff Andrew De Vera and explained the reason for the visit.

The investigation consisted of the following: LPA Villalobos obtained copies of the client and staff rosters, LPA interviewed staff #1-4 (S1-S4) and Clients #1-#16 (C1-C16), LPA obtained copies of documents from C1's file. The investigation revealed the following:

In regards to the allegation "Staff do not report incidents involving resident as necessary." it was alleged that the facility is not reporting incidents regarding C1 as needed. (4) of (4) Staff interviewed denied the allegation. (16) of (16) Clients interviewed could not corroborate the allegation. File review shows that police were called to facility on 8/9/22 for "vandalism" incident.

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

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
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 7
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
05/24/2023 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230524084358

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: 160DATE:
05/30/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Staff Andrew De VeraTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident is not being treated with dignity and respect.
Staff harass resident in care.
Staff do not safeguard resident’s belongings.
Staff do not ensure that resident(s) are provided with a safe environment
Staff did not provide facility safety plan to Resident's Representative upon request.
Staff do not respond to Resident's Representative's requests for communication in a timely manner.
Staff did not seek medical attention for resident in a timely manner.
Staff are not administering medications to resident as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced initial complaint visit for the allegation above. LPA met with Staff Andrew De Vera and explained the reason for the visit.

The investigation consisted of the following: LPA Villalobos obtained copies of the client and staff rosters, LPA interviewed staff #1-4 (S1-S4) and Clients #1-#16 (C1-C16), LPA obtained copies of documents from C1's file. The investigation revealed the following:

In regards to the allegation "Resident is not being treated with dignity and respect." it is alleged that C1 is mistreated by other clients in the facility for being white. (4) of (4) Staff interviewed denied the allegation. (16) of (16) Clients interviewed could not corroborate the allegation. Interviews do not show that clients or staff in the facility mistreat C1 or insult C1 based on their ethnicity. Interviews conducted state that it is C1 who uses slurs or derogatory remarks to insult other clients in care.

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: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 28-AS-20230524084358
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: 05/30/2023
NARRATIVE
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File review shows that C1 has a history of using "racist epithets" in the facility. Based on interviews and file review conducted; Although the allegation 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.

In regards to the allegation "Staff harass resident in care" it is alleged that S4 calls C1 names. (4) of (4) Staff interviewed denied the allegation. (16) of (16) Clients interviewed could not corroborate the allegation. Staff interviewed denied the allegations and stated no knowledge of S4 ever harassing clients in care. LPA was not provided with proof that staff harass C1. Based on interviews and file review conducted; Although the allegation 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.

In regards to the allegation "Staff do not safeguard resident’s belongings." it is alleged that facility staff did not safeguard C1's personal items when they were out of the facility. (4) of (4) Staff interviewed denied the allegation. (16) of (16) Clients interviewed denied the allegation. LPA was not provided with a list of items that were stolen from C1. File review does not show that facility were responsible for safeguarding C1's personal property. C1 refused interview and did not inform LPA of what items they may have had stolen. Based on interviews and file review conducted; Although the allegation 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.

In regards to the allegation "Staff do not ensure that resident(s) are provided with a safe environment" it is alleged that the facility staff do not protect residents from other residents as C1 was assaulted in the dining room by another client. (4) of (4) Staff interviewed denied the allegation. (16) of (16) Clients interviewed could not corroborate the allegation. LPA was not provided of the time the assault would have happened. File review does not show incident report or notes on file of C1 being assaulted by another client in the facility. Clients interviewed stated staff help with anything they need and are present to calm anyone down when needed. Clients interviewed stated they feel safe in the facility. Based on interviews and observations conducted; Although the allegation 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.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 28-AS-20230524084358
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: 05/30/2023
NARRATIVE
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In regards to the allegation "Staff did not provide facility safety plan to Resident's Representative upon request." it is alleged that a "safety plan" was requested from the facility but not provided. (4) of (4) Staff interviewed denied the allegation. (16) of (16) Clients interviewed could not corroborate the allegation. Interviews do not state that there is a specific "safety plan" in place for the facility. Interviews staff are aware of their responsibilities and duties as staff. LPA did not observe a safety plan in place, but did observe the plan of operations for the facility with the duties of staff and emergency and disaster plan. Based on interviews and observations conducted; Although the allegation 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.

In regards to the allegation "Staff do not respond to Resident's Representative's requests for communication in a timely manner." it was alleged that Staff do not respond to calls or communication from C1's representative. (4) of (4) Staff interviewed denied the allegation. (16) of (16) Clients interviewed could not corroborate the allegation. Interviews with staff state that S4 is in communication with C1's representative when needed. LPA was not provided with dates or times of when communicated from staff to C1's representative was requested. Based on interviews and observations conducted; Although the allegation 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.

In regards to the allegation "Staff did not seek medical attention for resident in a timely manner." it is alleged that C1 started exhibiting symptoms of having heart problems and other issues and the staff ignored it. (4) of (4) Staff interviewed denied the allegation. (16) of (16) Clients interviewed could not corroborate the allegation. Interviews do not show that C1's health issues are ignored in the facility. Review of C1's file shows a diagnosis of several health issues and is dated 10/1/22. Information provided to LPA states that these health issues were not discovered until March 2023, but file review contradicts the that statement. Based on interviews and file review conducted; Although the allegation 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.


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

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 28-AS-20230524084358
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: 05/30/2023
NARRATIVE
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In regards to the allegation "Staff are not administering medications to resident as prescribed." it is alleged that C1 arrived 15 minutes late to get their medications so staff refused to provide C1 their medications. (4) of (4) Staff interviewed denied the allegation. (16) of (16) Clients interviewed could not corroborate the allegation. Interviews with staff show that C1 is compliant with taking their medications everyday with no issues. Staff stated that clients have 2 hour windows for AM, PM, Evening, and Bedtime medications not 15 minute windows. LPA was informed that staff will search the facility for residents who do not come down for their medications and will also use the intercom systems. LPA reviewed C1's medication chart and did not observe missed or refused medications logged. Based on interviews and file review conducted; Although the allegation 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 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: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 28-AS-20230524084358
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: 05/30/2023
NARRATIVE
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 Interviews stated it was in regards to someone breaking into C1's room at that time and taking some of their personal belongings. Interviews do not show that the vandalism was caused by any other client in the facility or staff. Review of C1's file and review of reports submitted to Licensing do not show that the facility created an incident report to provide to licensing. This shows the facility failed to report the incident involving C1 as necessary. Based on LPA's interviews and records reviewed, the preponderance of evidence standard has been met, therefore the allegations are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099D.

Exit interview held and a copy of the report and appeal rights was provided and discussed.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 28-AS-20230524084358
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/09/2023
Section Cited
CCR
80061(b)(1)(E)
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80061.Reporting Requirements. (b) Upon the occurrence, during the operation of the facility...(1) Events reported shall include the following:(E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
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Facility Staff to review Reporting Requirements regulation 80061 and send Licensing a letter with signatures of completion by POC due date.
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This was not met as evidenced by: Police department was called in on 8/9/22 regarding vadalism but no incident report was provided to licensing or responsible parties. This poses a potential health and safety risk to clients in care and supervision.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7