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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 03/18/2024
Date Signed: 03/18/2024 04:06:32 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
03/15/2024 and conducted by Evaluator Erik Zaragoza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240315091758
FACILITY NAME:PICO RIVERA GARDENSFACILITY NUMBER:
198600539
ADMINISTRATOR:SANTOS DOMINGUEZFACILITY TYPE:
735
ADDRESS:6525 ROSEMEAD BLVD.TELEPHONE:
(562) 949-8489
CITY:PICO RIVERASTATE: ZIP CODE:
90660
CAPACITY:185CENSUS: 144DATE:
03/18/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Andrew De Vera - Administrator TIME COMPLETED:
04:21 PM
ALLEGATION(S):
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Staff does not ensure medications are dispensed in a sanitary manner to clients in care
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Erik Zaragoza and Daniel Konishi conducted an initial unannounced complaint visit to address the allegation listed above. LPAs met with Andrew De Vera, Administrator for the facility, and was granted access into the facility.

The investigation consisted of the following: LPAs obtained a copy of a staff and client roster, reviewed five (5) medicaitons along with their Medication Administration Records (MARs), interviewed Clients #1 - 17 (C1 - C17), and Staff #1 - 3 (S1 - S3), toured nine (9) bedrooms.

The investigation revealed the following: In regards to the allegation that "Staff does not ensure medications are dispensed in a santiary manner to clients in care," it is alleged that C1's medications have been contaminated by an object that appeared to be a flake of dead skin.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
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-20240315091758
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: 03/18/2024
NARRATIVE
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During interviews with the clients, sixteen (16) out of seventeen (17) clients did not corroborate the allegation. Most clients interviewed indicated that they had no issues with obtaining their medications, and they did not have any concerns about their medications becoming contaminated by the facility staff. During interviews with the staff, none of them corroborated that medications are becoming contaminated during the medication passes. One staff interviewed stated that the medication technicians for the facility dispense the medications straight from its bubble pack and into a plastic cup for the residents, and that it is provided to them with a glass water. The staff stated that it is possible that some debris from the capsule or tablet can break off and become scattered inside the medication cup when they dispense the medications into the plastic cup for clients, which can lead to the appearance that the medication cup has foreign substances in it, however the medications are not contaminated with any substance. LPAs also reviewed the medications and MARs for 5 random clients, including that of C1, and did not discover any deficiencies in the process of reviewing the medications.

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 allegations. 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.

Exit interview held, and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2