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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 02/08/2024
Date Signed: 02/08/2024 11:49:25 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
09/15/2023 and conducted by Evaluator Luis Mora
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230915152953
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: 147DATE:
02/08/2024
UNANNOUNCEDTIME BEGAN:
08:28 AM
MET WITH:Andrew Debera (Administrator)TIME COMPLETED:
12:05 PM
ALLEGATION(S):
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7
8
9
Staff do not conduct fire drills for the facility.
Staff do not report incidents to appropriate parties.
INVESTIGATION FINDINGS:
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7
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13
Licensing Program Analyst (LPA) Luis Mora conducted an unannounced subsequent complaint visit regarding the above allegations. LPA met with Andrew Debera (Administrator) and explained the reason for the visit.

The investigation consisted of the following: on 09/21/2023, LPA Mora obtained copies of staff & resident rosters, and interviewed Administrator and Staff 1 - Staff 4 (S1 - S4). During today's visit, LPA interviewed Client 1 - Client 7 (C1 - C7) and obtained copies of documentation of fire drill conducted on 09/22/2023, incident reports of missed and refused medication for the last 2 months, and a fire sprinkler test done on 10/04/2023.

The investigation revealed the following: regarding the allegation "staff do not conduct fire drills for the facility”, it is alleged that staff do not conduct fire drills however, staff completes the paperwork to appear as though fire drills are being conducted. (Continued to LIC 9099-C)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
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-20230915152953
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: 02/08/2024
NARRATIVE
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Interviews with Administrator and staff revealed that fire drills have not been conducted. Facility could not provide the LPA with previous documented fire drills. During today's visit, Administrator told the LPA that they conducted a fire drill on 09/22/2023 (a day after the LPA's first visit) and provided documentation of that fire drill. Clients interviewed corroborated the allegation.

Regarding the allegation "staff do not report incidents to appropriate parties”, it is alleged that staff do not send special incident reports regarding residents missing their medications or residents refusing to take medications. Interviews with Administrator and staff revealed that they were unaware that they needed to report this type of incidents to Community Care Licensing Division (CCLD). During today's visit, Administrator told LPA that they have already begun submitting incident reports to CCLD since the LPA's last visit and provided the LPA copies of incident reports for the last 2 months.

Based on LPA's interviews, records reviewed and observations, the preponderance of evidence standard has been met, therefore the allegations are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 1 are being cited on the attached LIC 9099-D.

Exit interview held and a copy of the report and appeal rights was provided.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20230915152953
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: 02/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/15/2024
Section Cited
CCR
80023(d)
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Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months

This requirement is not met as evidenced by:
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Facility is to ensure that Title 22 Section 80023 regulations are met at all times. Additionally, facility will submit a statement that they will comply with Title 22 Section 80023 to CCLD by 02/15/2024.
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Based on interviews and records review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Facility has not been conducting disaster drills.
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Type B
02/15/2024
Section Cited
HSC
80061(b)(E)
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Reporting Requirements
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) Events reported shall include the following: (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client....

This requirement is not met as evidenced by:
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Facility is to ensure that Title 22 Section 80061 regulations are met at all times. Additionally, facility will submit a statement that they will comply with Title 22 Section 80061 to CCLD by 02/15/2024.
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Based on interviews and records review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Facility has not been submitting incident reports of missed or refused medication to CCLD.
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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: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
09/15/2023 and conducted by Evaluator Luis Mora
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230915152953

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: 147DATE:
02/08/2024
UNANNOUNCEDTIME BEGAN:
08:28 AM
MET WITH:Andrew Debera (Administrator)TIME COMPLETED:
12:05 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Fire clearance.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Luis Mora conducted an unannounced subsequent complaint visit regarding the above allegations. LPA met with Andrew Debera (Administrator) and explained the reason for the visit.

The investigation consisted of the following: on 09/21/2023, LPA Mora obtained copies of staff & resident rosters, and interviewed Administrator and Staff 1 - Staff 4 (S1 - S4). During today's visit, LPA interviewed Client 1 - Client 7 (C1 - C7) and obtained copies of documentation of fire drill conducted on 09/22/2023, incident reports of missed and refused medication for the last 2 months, and a fire sprinkler test done on 10/04/2023.

The investigation revealed the following: regarding the allegation "fire clearance”, it is alleged that the facility's sprinklers do not work and that the fire department is complaining. Administrator and staff denied the allegation. To their knowledge the sprinklers are working and they have not heard any complaints from the fire department. (Continued to LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20230915152953
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: 02/08/2024
NARRATIVE
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3
4
5
6
7
8
9
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During the LPA's first visit on 09/21/2023, the facility did not have any records/reports of the fire sprinklers being tested. The facility contacted a company to inspect and test the facility's sprinklers and this was conducted on 10/04/2023. During today's visit, LPA reviewed the report and observed that the facility's sprinkler system pass the inspection.

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 held and a copy of the report was provided
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5