198600539-12-12-2023-28-AS-RORN-CZ4MHR-20240102083754

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 12/12/2023
Date Signed: 12/12/2023 09:47:50 AM

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 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: 140	DATE:	12/12/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Mary Marquez		TIME COMPLETED:	10:25 AM

ALLEGATION(S):

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Staff mismanaged residents' medications.
Facility has pests.

INVESTIGATION FINDINGS:

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***This report supersedes the previous complaint report dated 08/24/23. The reason it’s being superseded is to update the medication deficiency (80075(b)(5)(B) that was issued from a Type B to a Type A citation regarding allegation “staff mismanaged residents’ medications”. The finding remains the same. ***

The investigation revealed the following: Allegation "Staff mismanaged residents' medication" LPA reviewed/inspected 9 client’s medication and their MARs and 5 out of 9 clients' medication had some medication errors. They are included some clients' bubble pack medication was popped on the wrong date. Some medication was not popped even medication already started from the date of medication. Some clients were missing medication without any documentation. Some client's actual bubble medication was there but was not listed on the MARs. Some client's medication listed on the MARs, but the medication was not in the facility.

(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: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

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-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: 12/12/2023

NARRATIVE

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

***This report supersedes the previous complaint report dated 08/29/23. The reason it’s being superseded is to correct spelling errors and clarify the finding, “facility has pests”. The finding remains the same. ***

The investigation revealed the following: Allegation "Facility has pests" LPA interviewed 15 clients and 9 out of 15 clients reported the facility has pests. 3 out of 9 reported their room has 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 every day. Even though the facility sprayed they still saw it every day. 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 crawling on client's blanket. LPA also observed the dead roaches lying on the floor in the interview room.

Based on interview conducted, record review and LPA's observation, the preponderance of evidence standard has been met, therefore the above allegation is 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: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

LIC9099 (FAS) - (06/04)

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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: 12/12/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/13/2023 Section Cited CCR 80075(b)(5)(B)	1 2 3 4 5 6 7	80075(b)(5)(B) Health Related Services....... Medications shall be given according to physician's directions. The requirement was not met as evidenced by record review and LPA's observatiion:	1 2 3 4 5 6 7	Administrator will ensure that all staff have medication training by a trained professional on the disribution and logging of medications and will include how the facility will ensure that all medications are dispensed to clients according the prescription instructions
	8 9 10 11 12 13 14	LPA observed 5 out 9 client's medication had medication errors which posed an immediate risk to clients in care.	8 9 10 11 12 13 14	A list of all attendees of the trainng and the written plan will be submitted to LPA by POC due date. (POC Cleared on 09/01/23)-- LPA received a plan from the administrator about the medication error and the staff in service training log
Type B 12/19/2023 Section Cited CCR 80087(a)(1)	1 2 3 4 5 6 7	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	1 2 3 4 5 6 7	Licensee will ensure that the facilty is free of bed bugs at all times and send proof to LPA by POC due date.
	8 9 10 11 12 13 14	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.	8 9 10 11 12 13 14	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.

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: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

LIC9099 (FAS) - (06/04)

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