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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 01/25/2024
Date Signed: 01/25/2024 04:54:29 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
01/23/2024 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240123115558
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: 155DATE:
01/25/2024
UNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:Andrew De Vera, Assistant AdministratorTIME COMPLETED:
04:58 PM
ALLEGATION(S):
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Facility is operating beyond the scope of their license.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Lopez conducted an initial 10 days complaint visit to ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint. LPA met with the S#1 Assistant Administrator Andrew De-Vera and LPA explained the purpose of the visit.

The investigation consisted of the following: LPA Interviewed 5 staff (S#1-S#5) including Assistant Administrator, 15 clients C#1-C#15 and reviewed and obtained copies of staff and resident rosters, C1 Face sheet, admission agreement, C1 physician’s report, SIR dated 01/06/2024 and C#1 Property inventory. C1 P&I ledger.

The investigation revealed:
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
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 6
Control Number 28-AS-20240123115558
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: 01/25/2024
NARRATIVE
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The investigation revealed:

Allegation: Facility is operating beyond the scope of their license. It is alleged that two underage females are residing at the facility. LPA took tour of facility and interviewed 4 staff (S#1-S#4) and Sixteen clients C#1-C#16. 4 of 4 staff denied the allegation and stated that there are no minors residing at the facility and minors are not allowed in facility without prior authorization and would only be allowed in common areas if allowed at all. LPA interviewed 16 clients and 14 of 16 could not collaborate the allegations. 2 clients stated that they have seen young girls at facility but could not provide details or proof that they are under 18 years of age. Only that they look young. LPA checked the room in question and all tenants residing in that room were both over 18 years of age. LPA obtained documentation that roommate is over 18 years of age. LPA did not observe any clients in the facility that appeared to be under 18 years of age during the tour of facility and random rooms. LPA did not observe any drug activity during the visit. There is no evidence that roommate has contracted HIV or any other illness. There is no evidence that facility is operating beyond the scope of their license.

Based on file review, observations and interviewed conducted; 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 allegation is Unsubstantiated

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
01/23/2024 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240123115558

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: 155DATE:
01/25/2024
UNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:Andrew Devera, Assistant AdministratorTIME COMPLETED:
04:58 PM
ALLEGATION(S):
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Facility staff did not safeguard resident's personal belongings.
Illegal eviction.
INVESTIGATION FINDINGS:
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The investigation revealed:

Allegation: Facility staff did not safeguard resident's personal belongings. It is alleged that C1 property was stolen or missing. LPA interviewed 4 staff members and 4 of 4 staff denied the allegation. LPA interviewed 16 clients and 9 of 16 clients stated that have had personal property missing at one time or another. LPA obtained copy of C1 personal property and valuables list and the only item that was not accounted for was a Conair clipper. C1 stated C1 had a TV and microwave but there was no TV or microwave on C1 personal property and valuables list or in room, and P&I money is signed for by the C1. There was no evidence that C1 cash was stolen by staff at night.


(Continued on 9099A)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 28-AS-20240123115558
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: 01/25/2024
NARRATIVE
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Allegation: Illegal eviction. It is alleged that client was sent to hospital on 01/06/2024 after causing a fire by the patio and being placed on psychiatric hospital hold and not allowed to return. According to S1, C1 started a fire by the patio by burning some personal clothing and sheriff were called by facility staff. C1 was taken to hospital for evaluation and placed on psychiatric hold. S1 stated he will not be allowed to return to facility because he is a danger to himself and others at the facility. Client is still at hospital as of this report. LPA explained to Administrator that facility needs to properly evict resident and not just refuse him to return to facility.

Based on LPAs' observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Deficiency cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report was provided to Andrew De Vera, Administrator along with the Appeals Rights.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20240123115558
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: 01/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/01/2024
Section Cited
CCR
80026(b)
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80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents (b) If such a client is accepted for or maintained in care, his/her cash resources, personal property, and valuables not handled by a person outside the facility who has been designated by the client or his/her authorized representative shall be handled by the licensee or facility staff, and shall be safeguarded in accordance with the requirements specified in (c) through (n) below.
This requirement is not met evidenced by:
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Facility will replace conair clippers and make sure resident or representative receives them and send proof to LPA by POC date.
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C1 is missing one item (conair clippers) from his personal property inventory list.
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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: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20240123115558
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: 01/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/26/2024
Section Cited
CCR
80068.5(e)
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80068.5 Eviction Procedures.
(e) The licensee shall mail or fax to the Department a copy of the 30-day written notice in accordance with (a) above within five days of giving the notice to the client.

This requirement is not met as evidenced by:
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Administrator will provide written notice to client and/or representative of eviction and send CCL written notice of eviction by POC date.
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Administrator and other staff stated they will not allow C1 to return to facility due to being a safety to self and others. Facility failed to provide C1 or his representative written notice of eviction which is health and safety risk for persons in care.
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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: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6