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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 02/22/2024
Date Signed: 02/22/2024 03:21:15 PM

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
08/30/2023 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230830101223
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: 149DATE:
02/22/2024
UNANNOUNCEDTIME BEGAN:
07:58 AM
MET WITH:Administrator Andrew De-VeraTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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9
Staff do not keep the facility free of drugs.
Staff do not maintain the facility in a clean condition.
Staff only provide clients with old mattresses.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 02/22/2024. Health and Safety check was conducted on 08/31/2023 by LPA Villalobos and LPA Vaid and needs further investigation was documented. Subsequent complaint visit was conducted by LPA Calderon on 01/12/24 and a needs further investigation was documented. LPA Ramirez was met by Administrator Andrew De-Vera and explained the purpose of the visit.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Personnel Report (LIC 500), Resident Roster, Staff#1-4 interviews (S1-S4), Client interviews#1- 4 interviews (C1 – C4), Client#1- 5 (C1-C5): Emergency Contact Form, Physician Report, Appraisal/Needs and Services Plan for C1,Dewey Pest control Service Agreements and Quality Assurance Reports for various dates in 2024, other pertinent documents regarding this investigation and physical plant tour.

See 9099-C for continuation
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
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 8
Control Number 28-AS-20230830101223
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: 02/22/2024
NARRATIVE
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The investigation revealed the following. Regarding Allegation(s): Staff do not keep the facility free of drugs- It is alleged staff do not keep the facility free of drugs. Three (3) out of the four (4) staff interviewed confirmed this allegation. Four (4) out of the four (4) clients interviewed confirmed this allegation. During tour of first floor, LPA was walking down facility hallway in between rooms 10 -20, LPA Ramirez could smell a strong odor of marijuana in this hallway. Interviews with staff and clients confirmed that some clients smoke marijuana in their rooms and the smoke seeps into other client rooms and into other areas of the facility. LPA Ramirez will issue deficiency. Based on interviews and observations, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Staff do not maintain the facility in a clean condition- It is alleged that staff do not maintain the facility in a clean condition. Three (3) out of the four (4) staff interviewed confirmed this allegation. Four (4) out of the four (4) clients interviewed confirmed this allegation. During tour of second floor, LPA Ramirez observed the words “JURAME JURAME” sprayed painted in silver on the outside of client door# 209 and “UGLY” sprayed painted in silver on the outside of client door# 212. LPA Ramirez observed “Report Information and Victims’ Bill Rights (dated 2/12/24- Report# T-33), regarding the alleged property damage to the facility. LPA Ramirez observed an unknown wet substance on the stairs on stairway and a discarded stained white sheet or towel in the same stairways. LPA Ramirez took photos of observations. LPA Ramirez will issue deficiency based on observations and interviews. Based on interviews and observations, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Staff only provide clients with old mattresses- It is alleged the facility does not provide clients with clean and new mattresses. Four (4) out of the four staff interviewed deny this allegation. One (1) out of four (4) clients interviewed deny this allegation. During tour of random rooms, LPA Ramirez observed the mattress in room #27 to contain a burn mark in two places. Although the mattress was observed to contain a white plastic mattress protector, LPA Ramirez could see the outline impression of a burn and could feel the mattress springs through the mattress protector, directly over the burned area. LPA Ramirez took photos of mattress and will issue deficiency. Based on interviews and observations, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Exit interview was conducted. A copy of this report, 809-D and appeals rights was provided.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 8
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
08/30/2023 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230830101223

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: 149DATE:
02/22/2024
UNANNOUNCEDTIME BEGAN:
07:58 AM
MET WITH:Administrator Andrew De-VeraTIME COMPLETED:
03:40 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility has pests.
Staff do not ensure that clients have access to hot water at all times.
Staff do not adequately supervise the clients.
Staff do not ensure that a client is free of scabies.
Staff is not adequately trained.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
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13
Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 02/22/2024. Health and Safety check was conducted on 08/31/2023 by LPA Villalobos and LPA Vaid and needs further investigation was documented. Subsequent complaint visit was conducted by LPA Calderon on 01/12/24 and a needs further investigation was documented. LPA Ramirez was met by Administrator Andrew De-Vera and explained the purpose of the visit.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Personnel Report (LIC 500), Resident Roster, Staff#1-4 interviews (S1-S4), Client interviews#1- 4 interviews (C1 – C4), Client#1- 5 (C1-C5): Emergency Contact Form, Physician Report, Appraisal/Needs and Services Plan for C1,Dewey Pest control Service Agreements and Quality Assurance Reports for various dates in 2024, other pertinent documents regarding this investigation and physical plant tour.

See 9099-C for continuation
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
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 8
Control Number 28-AS-20230830101223
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: 02/22/2024
NARRATIVE
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The investigation revealed the following. Regarding Allegation(s): Facility has pests- It is alleged the facility has pests. Three (3) out of the four (4) staff interviewed confirmed this allegation. Four (4) out of the four (4) clients interviewed confirmed this allegation. LPA Ramirez observed Dewey Pest Control Service agreement and quality reports for various dates in January and February of 2024. LPA Ramirez did observe dead insects in nearby hallway. Although the facility does have an insect infestation, the facility is actively addressing the infestation. 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.

Staff do not ensure that residents have access to hot water at all times- It is alleged the facility has pests. Four (4) out of the four (4) staff interviewed deny this allegation. One (1) out of the four (4) clients interviewed confirmed this allegation. LPA Ramirez measured water temperature in room# 27 bathroom and water was within 105 to120 degree F. 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.

Staff do not adequately supervise the clients- It is alleged staff do not adequately supervise the clients. Four (4) out of the four (4) staff interviewed deny this allegation. One (1) out of the four (4) clients interviewed confirmed this allegation. During tour of facility, LPA Ramirez observed staff providing care and supervision to clients in care. LPA Ramirez observed the facility has video surveillance in most common areas and on the outside of the facility. LPA Ramirez did not observe any document to suggest staff are not adequately supervising clients 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.

Staff do not ensure that a client is free of scabies- It is alleged staff do not ensure that a client is free of scabies. Four (4) out of the four (4) staff interviewed deny this allegation. One (1) out of the four (4) clients interviewed confirmed this allegation. LPA Ramirez reviewed four (4) client records and did not observe any medical record with a diagnosis of scabies. LPA Ramirez did not observe an Unusual Incident/Injury Report (LIC 624) for any client regarding scabies. 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.

Staff is not adequately trained- It is alleged staff do not ensure that a client is free of scabies. Four (4) out of the four (4) staff interviewed deny this allegation. One (1) out of the four (4) clients interviewed confirmed this allegation. LPA Ramirez reviewed four (4) personnel records and training. LPA Ramirez observed annual training for all personnel records reviewed. LPA Ramirez observed First Aid and CPR training for four (4) out of the four (4) personnel records reviewed. 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.

No deficiency is being cited for these allegations. Exit interview was conducted. A copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 28-AS-20230830101223
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: 02/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/23/2024
Section Cited
CCR
80087(a)
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80087 Buildings 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 evidence by:
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Licensee will certify plan to address drug use in facility by 2/23/24. Plan must be submitted to LPA via email.
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LPA Ramirez observed a strong odor of marijuana in facility hallway in between rooms 10-20.
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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: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 28-AS-20230830101223
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: 02/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/23/2024
Section Cited
CCR
80087(c)
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80087 Buildings and Grounds
(c)All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.This requirement was not met as evidence by:
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Staff cleaned up stairway during visit. No futher action is required for this deficiency at this time. *LPA Ramirez will clear deficiency*
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LPA Ramirez observed unknown wet substance on stairway and disgarded white stained sheet or towel on stairway.
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Type B
02/23/2024
Section Cited
CCR
85088(c)(1)
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85088 Fixtures, Furniture, Equipment and Supplies (c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene.
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This requirement was not met as evidence by:
Room# 27 mattress was observed to have 2 burn marks.
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(1) An individual bed, except that couples shall be allowed to share one double or larger sized bed, maintained in good repair, and equipped with good bed springs, a clean mattress and pillow(s).

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Staff replaced mattress in room during visit.
No further action is required at this time. *LPA Ramirez will clear deficiency.*
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: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 8