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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 10/17/2023
Date Signed: 10/17/2023 03:03:43 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
07/31/2023 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230731161153
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: 136DATE:
10/17/2023
UNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Assistant Administrator Andrew De VeraTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Staff did not dispense medications as prescribed
Facility intercom system is in disrepair
Staff does not ensure the food being served is of good quality
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced subsequent complaint investigation visit for the allegation above. LPA met with assistant administrator Andrew De Vera and the purpose of the visit was discussed.

Initial visit on 8/8/23 consisted of the following: : LPA toured the physical plant, Interviewed Staff #1-#2 (S1-S2), collected copy of the staff and client roster, collected documents from Clients #1 (C1) and Client #2's (C2) file. The documents collected were the facesheet , physicians report, needs and services plan and current list of medication on the MARs.

On todays visit, LPA Villalobos conducted the following: LPA interviewed Client #3-#12 (C1-C12) and Staff #3-#7 (S3-S7), LPA toured the physcial plant and observed the food supply. The investigation revealed the following:

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: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
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-20230731161153
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: 10/17/2023
NARRATIVE
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In regards to the allegation "Staff did not dispense medications as prescribed" it was alleged that S3 dispensed the wrong medication dosage of Cyprexa to C1 recently. (7) of (7) Staff interviewed denied the allegation. (11) of (12) Clients interviewed could not corroborate the allegation. LPA was not provided with date of alleged medication error. File review does not show that there was a medication error for medication Cyprexa. File does not show that C1 receives that medication either. Interviews with (11) of (12) clients does not show that staff have had medication errors. Based on interviews, observations, and file review there was not enough supportive evidence to concur with the reported allegation. 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 allegation is UNSUBSTANTIATED.

In regards to the allegation "Facility intercom system is in disrepair" it was alleged that the intercom system does not function properly and staff have not repaired it. (7) of (7) Staff interviewed denied the allegation. (10) of (12) Clients interviewed could not corroborate the allegation. Interviews show that there is no knowledge that the intercom system is in disrepair. Interviews show that the intercom system may sound loud or low depending on the voice and pitch of the staff who uses it. The volume of the intercoms is not adjusted by any staff and always remains in a set volume. LPA observed the intercom speakers in the hallways to be functioning and in good repair. None were observed to be broken. LPA was not provided with proof that the intercom systems were in disrepair. Based on interviews, observations, and file review there was not enough supportive evidence to concur with the reported allegation. 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 allegation is UNSUBSTANTIATED.

In regards to the allegation "Staff does not ensure the food being served is of good quality" it was alleged that staff serve spoiled food to the clients such as bad meat or not fully cooked meat. (7) of (7) Staff interviewed denied the allegation. (10) of (12) Clients interviewed could not corroborate the allegation. It was alleged that the bacon served in the facility is served raw and other meats served with plastic still on them. Interviews conducted do not show clients being served raw bacon or food with plastic on them. LPA observed the food supply and there was no expired food observed. File review did not show any clients were served contaminated food or fell ill from eating the facility meals. Based on interviews, observations, and file review there was not enough supportive evidence to concur with the reported allegation. 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 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: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2