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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 06/15/2023
Date Signed: 06/15/2023 02:14:55 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
06/07/2023 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230607091100
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: 147DATE:
06/15/2023
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Assistant Administrator Andrew De VeraTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff threatened resident in care
Staff member speaks inappropriately to residents
Illegal eviction
Facility does not have hot water
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced initial complaint investigation visit for the allegation(s) listed above. LPA met with Assistant Administrator Andrew De Vera and the purpose of the visit was discussed.

LPA conducted the following on todays visit: Interviewed Staff #1-#5 (S1-S5), Clients #1-#14 (C1-C14), toured the physical plant, collected copies of the staff and client rosters. LPA also collected and reviewed documents from C2's file such as the Facesheet , physicians report, admissions agreement , medication record for the last 2 months , and needs and services plan.

The investigation revealed the following: In regards to allegation "Staff threatened resident in care" it was alleged that S2 threatens clients in care. (5) of (5) staff interviewed denied the allegation. (14) of (14) clients interviewed could not corroborate the allegation. LPA was not provided details or examples as to how S2 threatens residents in care... Continued on LIC9099-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: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
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-20230607091100
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: 06/15/2023
NARRATIVE
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LPA did not observe S2 threaten any clients in care during the visit. File review did not show history of S2 threatening clients in care. Based on interviews, observations 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 allegation is unsubstantiated.

In regards to the allegation "Staff member speaks inappropriately to residents" it was alleged that S2 speaks inappropriately to clients in care by being verbally aggressive. (5) of (5) staff interviewed denied the allegation. (14) of (14) clients interviewed could not corroborate the allegation. LPA was not provided details or examples as to how S2 is verbally aggressive to clients in care. Interviews with clients did not show that S2 is verbally aggressive to clients in care. LPA did not observe S2 speaking aggressively to clients in care. File review did not show a history of S2 being verbally aggressive to clients in care. Based on interviews, observations 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 allegation is unsubstantiated.

In regards to the allegation "Illegal eviction" it was alleged that the facility staff illegally evicted C2 from the facility. (5) of (5) Staff interviewed denied the allegation. (14) of (14) Clients interviewed could not corroborate the allegation. Interviews state that client C2 was not evicted from the facility and is still living here. LPA observed C2 to be living in the facility but C2 denied interview. File review did show that C2 was provided an eviction notice on 5/4/23 for house rule violations but is still a client in the facility. File review of incident reports also confirmed that on 5/31/23 , C2 was placed on a 51/50 hold at Exodus Hospital. No documentation stated that C2 was discharged from the facility. Interviews state C2 returned to the facility the next day and remains a client in care and supervision. LPA observed medications on file for C2. Based on interviews, observations 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 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: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20230607091100
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: 06/15/2023
NARRATIVE
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In regards to the allegation "Facility does not have hot water" it was alleged that the side A building does not have hot water. (5) of (5) Staff interviewed denied the allegation. (14) of (14) Clients interviewed could not corroborate the allegation. Interviews show that the facility had an issue where the water boiler for the side A building stopped working and needed to be replaced. Water boiler broke on 5/19/23 and when inspected, it was revealed that it could not be repaired and a new one needed to be ordered. New boiler was purchased and replaced by 5/30/23. During the time of 5/19-5/30 , Clients were provided accommodations to have access to hot water and the building noted as "Side B" still had hot water working. At the time of this visit, LPA observed the hot water temperatures in rooms #3, #4 , #10 , #14 , and #26, which are part of Side A and were compliant with Title 22 regulations. Interviews with clients stated there are no current issues with the hot water of the facility. Based on interviews, observations 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 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: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3