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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 01/12/2024
Date Signed: 01/12/2024 03:12:16 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
01/08/2024 and conducted by Evaluator Angelica Rea
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240108100937
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: 140DATE:
01/12/2024
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Andrew De Vera TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff are not following physician's orders.
Facility did not provide a safe environment for a resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angelica Rea conducted a visit in response to the above allegation. On today's visit, LPA met with Assistant Administrator Andrew De Vera who assisted with the visit.

Regarding the allegation that : Staff are not following physician's orders for resident #1. The investigation consisted of interviews with Staff #1- Staff #3, Resident #1- Resident #10, and review of resident #1's file, including medication administration record. Staff interviewed denied the allegation. They stated that staff are following physician's orders. Staff interviewed stated that residents are given their medication as prescribed. Residents interviewed were unable to corroborate the allegation. Nine out of ten residents interviewed stated that staff are following physician's orders, to their knowledge. Regarding the allegation that : Facility did not provide a safe environment for a resident in care, specifically that resident #1 is being bullied by other resident(s). The investigation consisted of interviews with Staff #1- Staff #3, and Resident #1 - Resident #10. Staff interviewed denied the allegation. Staff stated that they were not aware of any bullying incidents occurring at the facility.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
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-20240108100937
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: 01/12/2024
NARRATIVE
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Resident #1 was unable to provide name(s) of residents who are bullying him. Resident #1 stated that there were resident(s) who had previously challenged him to fight, but that was a long time ago. He stated that he currently doesn't have any issues with resident(s) bullying him. Residents interviewed were unable to corroborate the allegation. Nine out of Ten residents interviewed stated that the facility is providing a safe environment for resident(s) in care.

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 was conducted with Andrew De Vera and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2