198600539-4-4-2024-28-AS-RORN-D47MW3-20240410095740

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 04/04/2024
Date Signed: 04/04/2024 12:41:40 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
03/29/2024 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240329155227

FACILITY NAME:	PICO RIVERA GARDENS		FACILITY NUMBER:	198600539
ADMINISTRATOR:	SANTOS DOMINGUEZ		FACILITY TYPE:	735
ADDRESS:	6525 ROSEMEAD BLVD.		TELEPHONE:	(562) 949-8489
CITY:	PICO RIVERA	STATE: CA	ZIP CODE:	90660
CAPACITY:	185	CENSUS: 150	DATE:	04/04/2024
		UNANNOUNCED	TIME BEGAN:	08:59 AM
MET WITH:	Julia Elias, Med-Tech Supervisor		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Resident sustained unexplained injury while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted an initial 10-Day complaint visit to investigate the above allegations. The purpose of the visit was discussed with Medication Supervisor Julia Elias. Administrator Santos Dominguez was explained the purpose of the visit telephonically.

The investigation consisted of: A physical tour of the facility was conducted. Staff (S1- S7) and residents (R1-R11) were interviewed. Resident (R1's) file documents [Identification and Emergency Information, Preplacement Appraisal, Physician Report, Appraisal Needs/Services Plan, LIC 500 Personnel Report, and client rosters were obtained.

***Narrative continues next page. ****

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/04/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240329155227

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: 04/04/2024

NARRATIVE

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Allegation: Resident sustained unexplained injury while in care. It is alleged that several days ago resident (R1) woke up with burns on their chest and back. It was reported that the injury area bled and is now a scab. A total of seven (7) staff were interviewed of which all denied knowledge of R1's alleged burn injuries and/or reports by R1 of alleged injury/scabs. LPA and staff (S1) conducted an upper body check assessment during today's visit. It was observed that resident (R1) has one (1) quarter size red mark area with 3 dots in the left upper chest area, as well another red mark area located in the back shoulder/arm area that had 12 small old bloody dots. The affected areas showed signs of a bug/spider bite. Resident (R1's) housekeeper was interviewed, and stated that there are no current bed bugs in the resident's room, but has observed spider webs in the upper ceiling area. A total of 11 residents were interviewed. Three (3) out of the 11 residents stated they have been injured or have heard of residents being injured by other residents. For example, one (1) resident stated they have heard that a resident was pushed down the stairs, and another resident reported that approximately 2 months ago they were hit in the back of the head by another resident while walking in the facility hallways. Based on record review, R1 has history of impaired insight and hallucinations, and during today's body check assessment and interview the resident stated that the affected injury area is due to a burn. Based on observation, there is insufficient evidence to prove the affected area injury was caused by a burn.

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 was conducted with Med-Tech Supervisor Julia Elias . A copy of the report was issued.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/04/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

LIC9099 (FAS) - (06/04)

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