198600539-11-29-2023-28-AS-RORN-CYAR59-20231207114245

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 11/28/2023
Date Signed: 11/29/2023 08:37:41 AM

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
11/20/2023 and conducted by Evaluator Erik Zaragoza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231120090607

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: 146	DATE:	11/28/2023
		UNANNOUNCED	TIME BEGAN:	08:58 AM
MET WITH:	Fabiola Padilla - Med Tech		TIME COMPLETED:	12:18 PM

ALLEGATION(S):

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Staff did not protect resident's medication from being contaminated

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Erik Zaragoza conducted an initial complaint visit regarding the allegation listed above. LPA met with Fabiola Padilla, Med Tech for the facility, and explained the purpose for the visit. Assistant Administrator Andrew De-Vera arrived shortly thereafter.

The investigation consisted of the following: LPA conducted a tour of the medication room which is also where medications are dispensed to clients, and interviewed Clients #1 - 14 (C1 - C14), along with Staff #1 - 4 (S1 - S4). LPA also obtained a copy of the client and staff rosters, along with C1's FACE Sheet, Physician's Report, Pre-Placement Appraisal, and Appraisal/Needs and Services Plan. LPA attempted to interview Staff #5 (S5) however they left the facility before they could be interviewed.

***Continued on LIC9099-C***

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

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-20231120090607

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: 11/28/2023

NARRATIVE

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The investigation revealed the following: in regards to the allegation "Staff did not protect resident's medication from being contaminated," it is alleged that there was a fingernail found in C1's cup of medications, and that the counter that the staff hand clients their medication is constantly wet, causing the clients medication to become wet. During interviews with the clients, thirteen (13) out of fourteen (14) interviewed did not corroborate that their medications have been contaminated by the facility staff. C2 - C14 indicated that their medications are always provided to them in clean and good condition, as if right out of their bubble-packs, and and that they do not have any concerns with their medication being contaminated. C1 showed LPA a picture of the supposed fingernail they found in their medication cup, however LPA determined that this was not a fingernail, and instead appeared to be an indentation of the bottom of the cup, while the administrator explained it was a piece of his capsule medication. During interviews with Staff, none of them corroborated the allegation that client medications have been contaminated with a fingernail or any other substances. S1 explained that during the night shift the Med Techs pop client's medication from their bubble-packs directly into cups for the following day with gloves on to prevent medication. Additionally S3 stated that while there is sometimes water on the counter in which they place the clients medication cups due to a small spill from water that they also provide clients when they give their medications, the spillage never comes into contact with the client's medications as the medications are always separated by the cup they are placed in.

Based on statements and interviews conducted with staff, clients, review of client files and facility file records, 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 held, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

LIC9099 (FAS) - (06/04)

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