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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 04:21:47 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
07/17/2023 and conducted by Evaluator Jewel Baptiste
COMPLAINT CONTROL NUMBER: 28-AS-20230717113356
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:
08:54 AM
MET WITH:Assistant Administrator Andrew De Vra TIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Facility has lice
Resident not accorded privacy
Staff are not properly trained
INVESTIGATION FINDINGS:
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On 1/25/2024 at 8:54 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced subsequent complaint investigation visit for the allegations above. LPA met with Assistant Administrator Christina Vasquez and the purpose of the visit was discussed. Assistant Administrator Andrew De Vra joined the visit at 9:50 a.m.

During the initial visit LPA Baptiste interviewed the Administrator and Staff #1-#3 (S1-S3) and clients #3-#13 (C3-C13). C1 was not available for interview. LPA collected copies of Dewey pest control bill dated 7/1/2023, Staff roster, Client Roster and took photos of bed bugs in room #7. LPA reviewed C1 and C2's file and collected copies of their admission agreement, needs and services plan, Identification and Emergency Information, Preplacement appraisal information, Appraisal needs and services plan, and medications list. LPA additionally conducted a tour of the physical plant.

Report continued 9099c
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
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 5
Control Number 28-AS-20230717113356
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: 01/25/2024
NARRATIVE
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During todays visit LPA interviewed the Administrator and Staff #1-#3 (S1-S3) and clients #1-#13 (C1-C13). LPA obtained staff roster, client roster, took photos of furniture in common areas and client’s rooms (back patio, T.V. room, dining room, and activities room), and conducted file review for C2 and C3.

Regarding the allegation “Facility has lice " it was alleged that residents have lice. The administrator denied the allegation stating there is no confirmed cases in the facility. 3 out of 4 staff denied the allegation stating there are no confirmed cases of lice. 1 out of 4 staff stated there was 1 case of lice, but it was not confirmed by a doctor. 1 out of 15 clients stated they had lice and the facility treated them. They further stayed that it was not confirmed by a physician. 1 out of 15 clients stated they never had lice but have seen clients with what looked like lice. 13 out of 15 clients stated they never had lice and have not witnessed other clients with lice. LPA conducted file review and did not observe confirmation of lice from a physician.

Regarding the allegation " Resident not accorded privacy " it was alleged that C2 listens to C1 phone calls. The administrator denied the allegation stating there have been no complaints from the clients regarding privacy. 4 out of 4 staff denied the allegation stating staff has always knocked before entering the client’s room and they try to match roommates that alike to prevent issues. 2 out of 15 clients stated they don’t have privacy due to drugs in the facility. 3 out of 15 clients stated they have enough privacy in their room.

Regarding the allegation " Staff are not properly trained “it was alleged that the med techs are not properly trained. The administrator denied the allegation stating all staff are trained. 4 out of 4 staff denied the allegation stating staff are trained. 15 out 15 clients stated they are unaware of staff training. LPA reviewed training for the Med techs and confirmed trainings.

Based on LPA's interviews, investigation revealed: 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.



Exit interview conducted with Andrew De Vra and a copy of this record provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
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 5
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
07/17/2023 and conducted by Evaluator Jewel Baptiste
COMPLAINT CONTROL NUMBER: 28-AS-20230717113356

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:
08:54 AM
MET WITH:Assistant Administrator Andrew De Vra TIME COMPLETED:
04:40 PM
ALLEGATION(S):
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9
Staff are not providing adequate furniture for residents.
INVESTIGATION FINDINGS:
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On 1/25/2024 at 8:54 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced subsequent complaint investigation visit for the allegations above. LPA met with Assistant Administrator Christina Vasquez and the purpose of the visit was discussed. Assistant Administrator Andrew De Vra joined the visit at 9:50 a.m.

During the initial visit LPA Baptiste interviewed the Administrator and Staff #1-#3 (S1-S3) and clients #3-#13 (C3-C13). C1 was not available for interview. LPA collected copies of Dewey pest control bill dated 7/1/2023, Staff roster, Client Roster and took photos of bed bugs in room #7. LPA reviewed C1 and C2's file and collected copies of their admission agreement, needs and services plan, Identification and Emergency Information, Preplacement appraisal information, Appraisal needs and services plan, and medications list. LPA additionally conducted a tour of the physical plant.
Report continued on 9099c
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
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 5
Control Number 28-AS-20230717113356
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: 01/25/2024
NARRATIVE
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Regarding the allegation " Staff are not providing adequate furniture for residents " it was alleged that there is no seating (furniture) throughout the facility to sit on and the furniture that is there is old and worn out and the facility looks vacant. The administrator denied the allegation stating there is adequate furniture in the common areas and the facility will repair them when they are broken. 4 out of 4 staff denied the allegation stating there is furniture for in all the common areas. 2 out of 15 clients stated there is not enough furniture in the common areas. 13 out of 15 clients confirmed there is enough, and the facility will repair them when it needs to be repaired. LPA toured the facility and took photos of furniture in the common areas that need to be repaired. In the TV room, the couch cushions were in disrepair. In the dinning room 4 chairs need to be repaired and the chairs in the back patio need to be cleaned.

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



Exit Interview Conducted with Assistant administrator/ Appeal Rights Provided / A Copy of the Report Issued.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
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 5
Control Number 28-AS-20230717113356
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/07/2024
Section Cited
CCR
80087(a)
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80087 Building 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.
This requirement was not met as evidenced by:
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The facility will ensure furnature is clean and in good repair at all times. Photo proof of the repaired furnature will be sent to LPA by POC due date.
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Based on observation, and interviews conducted it was revealed that the TV room, couch cushions were in disrepair. In the dinning room 4 chairs need to be repaired and the chairs in the back patio needed to be cleaned, which poses an potential health,
safety, or personal rights risk to 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: Jewel Baptiste
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 5