198600539-11-9-2023-28-AS-RORN-CY2PQ6-20231129103038

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 11/09/2023
Date Signed: 11/09/2023 02:23:16 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
11/02/2023 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231102091624

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:	11/09/2023
		UNANNOUNCED	TIME BEGAN:	12:46 PM
MET WITH:	Andrew Debera – Administrator		TIME COMPLETED:	02:37 PM

ALLEGATION(S):

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Staff did not protect resident's medication and water from being contaminated

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced initial complaint visit to determine the validity of the above-mentioned allegation. LPA met with Andrew Debera (Administrato) and explained the reason for the visit.

The investigation consisted of the following: LPA Mora obtained copies of the client and staff rosters, interviewed Administrator, Staff 1 - Staff 3 (S1 - S3), Client 1 - Client 11 (C1 - C11) and toured the medication room.

The investigation revealed the following: regarding the allegation "staff did not protect resident's medication and water from being contaminated”, it is alleged that there was a black rock inside a client's medication cup and the water given to take the medication had feces all around it and there were flakes of feces inside the cup. Administrator and staff denied the allegation. (Continued to LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

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-20231102091624

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: 11/09/2023

NARRATIVE

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LPA was shown a picture of the alleged cup with the black rock inside. LPA observed the picture and saw that at the bottom of the see-through plastic cup there was very tiny black piece of something. It did not appear to be a rock because it did not look round, but instead it looked flat. However, LPA could not distinguish if it was inside the cup or on the outside bottom of the cup. LPA asked the client if the client confirmed that it was a rock and that it was inside the cup. The client was hesitant that it was a rock but did not touch it to confirm nor did the client confirm that it was inside the cup. LPA toured the medication room and did not observe any rocks. The medication room door has a window and a wooden counter where the clients come to pick up their medication. LPA noticed that some parts of the wooden counter had tiny flat pieces of dark wood peeling off. It is unknown if a piece of that wood somehow went inside the cup or if it got stuck to the bottom of the cup. There was no pictures of the alleged cup of water with feces. Clients interviewed could not corroborate the allegation and 10 out 11 stated their medication and/or water has never been contaminated with rocks, feces or any other substances.

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 held and a copy of the report was provided

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

LIC9099 (FAS) - (06/04)

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