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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 07/21/2023
Date Signed: 07/21/2023 02:26:44 PM

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
07/19/2023 and conducted by Evaluator Bennette Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230719151400
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: 150DATE:
07/21/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Andrew DeVera - Asst. AdministratorTIME COMPLETED:
02:35 PM
ALLEGATION(S):
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Resident pushed another resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced complaint visit regarding the above stated allegation. LPA met with Andrew DeVera, Assistant Administrator and explained the reason for the visit.

The investigation consisted of the following: LPA obtained copies of Client & Staff Rosters, House Rules, and conducted a tour of facility including the common areas. LPA reviewed files for Client #1 (C1) and obtained copies of the following documents: Identification and Emergency Information Sheet, Physician Report, and Resident Appraisal. LPA also interviewed Staff #1 (S1) - Staff #5 (S5), and Client #3 (C3) – Client #12 (C12). LPA attempted to interview Client #1 (C1) but refused to speak with anyone during the visit. LPA also attempted to interview Client #2 (C2) but was at the Hospital.

The investigation revealed the following: In regards to the allegation " Resident pushed another resident in care,” it is alleged that a client grabbed another client by the right arm and pushed her causing her to stumble backwards. Client hit a wall, no visible injuries and refused medical attention. No other details provided. ***CONTINUED ON LIC9099-C*****
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
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-20230719151400
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: 07/21/2023
NARRATIVE
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Investigation revealed the following:

Interviews conducted with S1-S2 revealed that they were not aware of the incident and did not witness the alleged incident. 3 out of 5 staff stated that they heard about the incident from another staff but they did not witness the alleged incident. Staff members interviewed indicated that if they witness an altercation between clients they will attempt to stop the altercation and will notify facility management immediately. Facility staff will also contact Law Enforcement and seek medical attention for clients if needed. None of the clients interviewed indicated that they did not witness the alleged incident between C1 and C2. Clients interviewed indicated that they feel safe and comfortable at the facility and confirmed that facility staff will intervene during client-on-client altercations. Therefore, there was insufficient evidence to corroborate with this allegation.

Based on statements and interviews conducted with clients and staff as well as reviewed files, there was not enough supportive evidence to corroborate the 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, a copy of this report and Appeals Rights were provided to the Assistant Administrator, Andrew De Vera.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2