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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 03/29/2024
Date Signed: 03/29/2024 12:27:28 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
03/12/2024 and conducted by Evaluator Erik Zaragoza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240312155629
FACILITY NAME:PICO RIVERA GARDENSFACILITY NUMBER:
198600539
ADMINISTRATOR:SANTOS DOMINGUEZFACILITY TYPE:
735
ADDRESS:6525 ROSEMEAD BLVD.TELEPHONE:
(562) 949-8489
CITY:PICO RIVERASTATE: CAZIP CODE:
90660
CAPACITY:185CENSUS: 143DATE:
03/29/2024
UNANNOUNCEDTIME BEGAN:
08:03 AM
MET WITH:Faviola Padilla - Med TechTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Facility doesn't have a qualified administrator
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Erik Zaragoza conducted a subsequent complaint visit to address the allegation listed above. LPA was met with Faviola Padilla, Med Tech for the facility, and explained the purpose of the visit.

The investigation consisted of the following: During the initial visit conducted on 3/18/2024, LPA Erik Zaragoza obtained a copy of a staff and client roster, reviewed the medications for five (5) randomly selected clients along with their Medication Administration Records (MARs), interviewed Clients #1 - 17 (C1 - C17), and Staff #1 - 3 (S1 - S3), and toured nine (9) client bedrooms. Since the initial initial visit, Staff #4 (S4) was interviewed, and during today's visit LPA interviewed Staff #5 (S5) and delivered findings.

The investigaiton revealed the following: In regards to the allegation that the "Facility doesn't have a qualified administrator," it is alleged that S1 is impersonating an Adult Residential Facility (ARF) administrator, however they do not have an active administrator's certificate.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
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-20240312155629
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: 03/29/2024
NARRATIVE
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During interviews with the staff, none corroborated the allegation that the facility does not have a qualified administrator. During interviews with S1, they explained that they submitted their application to become a certificate administrator with the Administrator Certification Bureau (ACB) in either March or May of 2023, however they have still not received their certificate in the mail due to their backlog and therefore their certificate is still currently pending. S1 explained that as of now the current administrator is Santos Dominguez, who is also listed as the administrator in our department's records. LPA interviewed Santos over the phone regarding the allegation that the facility does not have a current listed administrator, and Santos advised that he is the current administrator for the facility, and comes in to the facility to provide consultation to S1, the medication supervision for the facility, as well as the maintenance supervisor for the facility until S1 receives their Administrator's certificate from ACB. Santos said he submitted his application for his administrator's certificate to be recertified, however due to ACB's backlog he also has not yet received his certificate. On 3/20/2024, LPA received confirmation from ACB that Santos' administrator's certificate had been renewed, and that it is effective from 8/27/2023 - 8/26/2025.

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: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2