198600539-8-31-2023-28-AS-RORN-CW9MCY-20231003093020

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 08/31/2023
Date Signed: 08/31/2023 05:31:50 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
08/28/2023 and conducted by Evaluator Jose Villalobos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230828085759

FACILITY NAME:	PICO RIVERA GARDENS		FACILITY NUMBER:	198600539
ADMINISTRATOR:	MEIR SHAUL YITZI TEICHMAN		FACILITY TYPE:	735
ADDRESS:	6525 ROSEMEAD BLVD.		TELEPHONE:	(562) 949-8489
CITY:	PICO RIVERA	STATE: CA	ZIP CODE:	90660
CAPACITY:	185	CENSUS: 147	DATE:	08/31/2023
		UNANNOUNCED	TIME BEGAN:	08:10 AM
MET WITH:	Assistant Administrator Andrew De Vera		TIME COMPLETED:	01:29 PM

ALLEGATION(S):

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Staff do not maintain facility clean and sanitary at all times
Staff did not ensure medication was correctly dispensed as prescribed to client in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jose Villalobos and Sanjay Vaid conducted an unnanounced complaint investigation for the allegation(s) listed above. LPA's met with assistant administrator Andrew De Vera and the purpose of the visit was discuseed.

Todays visit consisted of the following: LPA's interviewed staff #1-#5 (S1-S5) and Clients #1-#15(C1-C15). LPA's toured the physical plant and oberved the food supply. LPA's reviewed medication records and medications on hand for C1. LPA's collected a copy of the current staff and client roster as well as the medicatoin records for C1 for the month of August. The investigation revealed the following:

In regards to the allegation "Staff do not maintain facility clean and sanitary at all times" it was alleged that there are clients urinating in the stairways and staff are not addressing the issue. (5) of (5) Staff interviewed denied the allegation...

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: 08/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230828085759

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: 08/31/2023

NARRATIVE

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(14) of (15) Clients interviewed could not corroborate the allegation. Interviews do not show that clients are urinating in the hallways or stairways of the facility. Staff interviewed denied any knowledge of clients urinating in the stairways. No interviews provided LPA's with names or witness accounts of clients urinating in the stairways of the facility. LPA's did not observe urine on the walls or the stairways of the facility during the visit. Based on the interviews conducted and observations, 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 did not ensure medication was correctly dispensed as prescribed to client in care" it was alleged that the facility staff could identify a white powder on C1's medication. (5) of (5) Staff interviewed denied the allegation. (14) of (15) Clients interviewed could not corroborate the allegation. Interviews show that medications are popped out of the their tabs and put in a plastic cup daily for all clients in the facility. All the cups are new daily and none are reused. Interviews state that when some medication are popped out, due to the texture of the pills, small scratches or scapes cause them to flake or appear like dust. Staff denied ever placing any unknown substances in the clients medications. AM, Noon, and PM medications are popped out appropriately and provided to residents at their prescribed times. LPA did not observe medication error notes on file and C1 stated they took their medications normally. Based on the interviews conducted, file review, and observations, 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: 08/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

LIC9099 (FAS) - (06/04)

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