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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 08/29/2023
Date Signed: 08/29/2023 03:58:12 PM

Substantiated


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
08/21/2023 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230821085323
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:
08/29/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Andrew DeVera TIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Facility has pets
Staff does not ensure that residents receive quality food.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wong conducted a “Subsequent” visit to ascertain additional information regarding the above-mentioned allegation(s) and for the purpose of rendering the findings. LPA met with Administrator Andrew DeVera who allowed entry into the facility and assisted with the visit.

The investigation consisted of the following: On 8/24/23, LPA conducted an initial 10 days complaint visit and interviewed administrator, reviewed/inspected 9 clients' medication and their Medication Administration Record (MARs), obtained copy of clients and staff roster and a copy of Pest Control service agreement and Quarterly report and facility food menu from 8/13/23 to 8/26/23. On today's date, LPA interviewed fifteen (15) clients (C1-C15), four staff via telephone, three staff at the facility and tour the facility room# 28, 55 and 16 and the facility kitchen.

(See LIC 9099C for continuation)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
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 5
Control Number 28-AS-20230821085323
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: 08/29/2023
NARRATIVE
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The investigation revealed of the following : Allegation#1 "Facility has pets" LPA interviewed 15 clients and 9 out of 15 clients reported the facility has pets. 3 out of 9 reported their room have bed bugs and they are still active in their rooms and they do get bed bugs bites too. 6 out of 9 reported their rooms have roaches everyday. Even though the facility sprayed but they still saw it everyday. LPA interviewed staff, staff reported its under control and they do have pest control company comes regularly. During the room tour of the facility, LPA observed two bed bugs were crawling on client's blanket. LPA also observed the dead roaches lying on the floor in the interview room.

Allegation#2 "Staff does not ensure that residents receive quality food." LPA interviewed 15 clients and 8 out of 15 clients reported the food is awful and terrible. The food has no favor, no seasoning, no variety and always served the same food weekly and monthly. LPA interviewed the staff and reported no clients ever complained to them about food. During the tour of the kitchen, LPA observed some of the bread were expired and still on the shelf in the pantry and reported that they are still serving to clients.

Based on interview conducted, record review and LPA's observation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulation, Title 22 are being cited on the attached LIC9099D.

Exit Interview Conducted with Administrator Andrew De Vera / Appeal Rights Provided / A Copy of the Report Issued.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
08/21/2023 and conducted by Evaluator Christine Wong
COMPLAINT CONTROL NUMBER: 28-AS-20230821085323

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:
08/29/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Andrew DeVera TIME COMPLETED:
04:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not maintain facility in a clean and sanitary manner.
Facility temperature is uncomfortable
INVESTIGATION FINDINGS:
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2
3
4
5
6
7
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9
10
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13
Licensing Program Analyst (LPA) Wong conducted a “Subsequent” visit to ascertain additional information regarding the above-mentioned allegation(s) and for the purpose of rendering the findings. LPA met with Administrator Anderw DeVera who allowed entry into the facility and assisted with the visit.

The investigation consisted of the following: On 8/24/23, LPA conducted an initial 10 days complaint visit and interviwed administrator, reviewed/inspected 9 clients' medication and their Medication Administration Record (MARs), obtained copy of clients and staff roster and a copy of Pest Control service agreement and Quarterly report and faciltiy food menu from 8/13/23 to 8/26/23. On today's date, LPA interviewed fifteeen (15) clients (C1-C15), three staff via telephone, four staff at the facility and tour the facility room# 28, 55 and 16 and the facility kitchen.

(See LIC 9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20230821085323
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: 08/29/2023
NARRATIVE
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The investigation revealed of the following : Allegation#1 "Staff does not maintain facility in a clean and sanitary manner." LPA interviewed 15 clients and 15 out of 15 reported most of the time, the facility is clean and sanitary. They reported the staff tried their best to clean. They clean the common area and mop the floor twice a day. LPA interviewed the staff and reported they tried their best to keep the facility clean and its a lot better than before.

Allegation#2 "Facility temperature is uncomfortable" LPA interviewed 15 clients and 15 out of 15 reported the facility air conditioning is working well. They feel comfortable in their rooms or in the facility. LPA interviewed staff and reported one of the clients' room air conditioning is not working but they already asked the technician to come and fix it as some parts were broken. Facility does provide fan to the clients, so clients won't feel too hot in their rooms.

Based on statements and interviews conducted with staff, clients, and LPA's observations, there was not enough supportive evidence to concur with the reported allegations. Although the allegations 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 to Andrew De Vera, Administrator.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20230821085323
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
09/05/2023
Section Cited
CCR
80087(a)(1)
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80087 Buildings and Grounds(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
(1) The licensee shall take measures to keep the facility free of flies and other insects. The requirement was not met as evidenced
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Licensee will ensure that the facilty is free of bed bugs at all times and send proof to LPA by POC due date.
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by LPA's observation and interview conducted by clients and LPA observed two bed bugs were crawling on client's blanket and 9 out of 15 clients were reported facility has pets which posed a potenial risk to clients in care.
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POC Cleared: At the facility visit, LPA received the updated pest control company report and the facility had been address the issues with the pest control company.
Type B
09/05/2023
Section Cited
CCR
80076(a)(1)
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80076 Food Services (a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. The requirement was not met as evidenced by :
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Administrator will ensure the food shall be safe and of the quality necessary to meet client's needs. The administrator will send the plan to LPA by POC due date.
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LPA's observation and interviews conducted by client. LPA observed some of the bread on the kitchen pantry were expired and reported its still serving to the client. 8 out of 15 clients reported the food were awful and terrible with no favor, taste and variety.
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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: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5