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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 03/19/2024
Date Signed: 03/19/2024 12:25:08 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
08/09/2022 and conducted by Evaluator Nune Margaryan
COMPLAINT CONTROL NUMBER: 28-AS-20220809083340
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: 142DATE:
03/19/2024
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Andrew De VeraTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Staff mismanaged resident’s medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nune Margaryan conducted a subsequent complaint visit to deliver the finding to the above allegation. LPA met with Interim Administrator Andrew De Vera and explained the reason for the visit.
The initial complaint visit was conducted on 08/16/2022. During the initial visit, LPA obtained a copy of the Client Roster and Staff Roster, Medication Administration Report (MAR), Review C1’s file and obtained copies of relevant documents. Interviews conducted with Supervisor, Staff #1 (S1) to Staff #5 (S5) and Client #1 (C1) to Client #6 (C6).
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
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-20220809083340
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: 03/19/2024
NARRATIVE
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Regarding allegation. “Staff mismanaged resident’s medication”. It was alleged that on an unknown date staff gave C1 only one medication, but they wrote two medications were administrated in the logbook.
Interviewed Supervisor and staff who administer medications, denied the allegation. They stated that staff administrate all medications according to doctors note. Interviewed staff denied that they gave only one medication to C1 and signed for 2 medications. They stated that staff only signed the MAR when clients are refusing to take the medications. The Medication Administration Record (MAR) was reviewed which confirmed the staff statement, and LPA didn’t observe any discrepancies. 5 out of 6 clients stated that they do not have any concerns regarding their medications.

Although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted and the copy of this report was provided to Andrew De Vera.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2