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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 07/03/2023
Date Signed: 07/03/2023 02:41:19 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
06/26/2023 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230626141207
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: 140DATE:
07/03/2023
UNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Andrew De Vera TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff overdosed resident while in care

Staff failed to provide a comfortable environment for residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegations. LPA met with Assistant Administrator Andrew De Vera and explained the purpose for the visit.

The investigation consisted of: LPA Villalobos interviewed Staff #1-#5 (S1-S5) and clients #1-#14 (C1-C14). LPA collected copies of Staff and Client Rosters. LPA reviewed C1's file and collected copies of facility documents relevant to the investigation. LPA additionally conducted a tour of the physical plant. The investigation revealed the following:

In regards to the allegation of "Staff overdosed resident while in care" it was alleged that staff overdosed C1. (5) of (5) Staff interviewed denied the allegation. (13) of (14) Clients interviewed could not corroborate the allegation. LPA was not provided details of how C1 was overdosed in the facility.

(See LIC9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2023
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 2
Control Number 28-AS-20230626141207
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: 07/03/2023
NARRATIVE
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 Review of C1's file does not show C1 going to the hospital for medication overdose or other overdose reasons. There are no notes on file of C1 being overdosed in the facility. Interview with C1 states they have not overdosed in the facility. Based on interviews, observations, and file review 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 allegation "Staff failed to provide a comfortable environment for residents" it was alleged that facility staff scream into the intercom system making it loud and uncomfortable to clients in care. (5) of (5) Staff interviewed denied the allegation. (13) of (14) Clients interviewed could not corroborate the allegation. While touring the physical plant of the facility, LPA Villalobos did not observe the intercom systems volume bothering clients in care. Interviews with Clients does not show that the speaker volume bothers them. Clients interviewed stated that the volume is good enough to be heard around the facility and from clients rooms. Staff interviewed stated they do not yell into the intercom system and do not attempt to hurt any clients with the sound of the intercoms. Based on 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.

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: 07/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2