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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 04:10:54 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
05/18/2022 and conducted by Evaluator Ashley Calderon
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220518133814
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: 144DATE:
01/12/2024
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Iterm-Administartor: Andrew De Vera TIME COMPLETED:
04:10 PM
ALLEGATION(S):
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Staff hit resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Calderon conducted a subsequent complaint investigation for the allegation listed above. LPA met with Interm-Administrator Andrew De Vera and discussed the purpose of today's visit.

Investigation consisted of the following: the initial complaint visit was conducted on 05/25/22 by LPA Jose Villalobos. LPA Calderon conducted client interviews on 10/27/23 with client #1-client #15 (C1-C15).A subsequent visit was conducted today on 1/12/24 during subsequent complaint visit, LPA Calderon interview Interm-Administrator Andrew De Vera, Staff #1-Staff #3 and Staff #5 and Staff #7 (S1-S3, S5 and S7), attempt interview with Staff #4 (S4) via telephonically. LPA interviewed via telephonically reporting party, attempt interview via telephonically with case manager from Masada Homes. LPA attempt to interview client #16 (C16).

Continuation on 9099-C
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Ashley Calderon
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-20220518133814
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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Based on Allegation: Staff hit resident. The investigation revealed: Interviews conducted on 10/27/23 with Client #1- Client #15 (C1-C15) informed LPA that they do not know of any staff hitting a client and have not had any staff hit client(s). LPA during interviews with staff conducted on 1/12/24, 6 out 6 staff stated staff do not hit clients. 4 out 6 staff including Interm Administrator informed LPA that in 2022 there were no clients who were hit by staff. S3 and S4 could not collaborate with the above allegation, as they informed LPA that they were not working during with the facility in 2022. LPA during visit on 10/27/23 and 1/12/24 did not see any staff hit clients and did not observe any health and safety concerns.

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 allegation. 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.

An exit interview was held, and hard copy was this report will be provided via email.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Ashley Calderon
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