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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 04/23/2024
Date Signed: 04/23/2024 03:11:19 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
04/18/2024 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240418085317
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: 145DATE:
04/23/2024
UNANNOUNCEDTIME BEGAN:
08:51 AM
MET WITH:Administrator Andrew DeVeraTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not treat client with dignity and respect.
Staff did not provide a comfortable environment for client.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 04/23/2024. LPA Ramirez conducted initial complaint investigation visit on 3/28/24 and a needs further investigation was needed. 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#1-3 interviews (S1-S3), Client interviews#1- 3 interviews (C1 – C3), Client#1- (C1): Emergency Contact Form, Physician Report, Appraisal/Needs and Services Plan for C1, 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: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024
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-20240418085317
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: 04/23/2024
NARRATIVE
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The investigation revealed the following. Regarding Allegation(s): Staff did not treat resident with dignity and respect- It is alleged staff do not treat C1 with dignity and respect. Three (3) out of the three (3) staff interviewed denied this allegation. Three (3) out of the three (3) clients interviewed denied this allegation. LPA Ramirez reviewed C1’s client record and did not observe any document indicating C1 was not treated with dignity and respect by staff. C1 has a documented history of making false allegations. Although the allegation 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 did not provide a comfortable environment for client- It is alleged that staff did not provide a comfortable environment for client. LPA Ramirez toured C1’s shared room and did not observe any hazards. Three (3) out of the three (3) staff interviewed denied this allegation. Three (3) out of the three (3) clients interviewed denied this allegation. Interview with C1, revealed C1 is unhappy with their new roommate and is having difficulty adjusting to their new roommate and their roommates’ habits. Tour of physical plant did not reveal any immediate health and safety violations. Although the allegation 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.

Based on LPA’s interviews, observations and records reviewed during this investigation, no deficiencies are being cited today. Exit interview conducted and 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: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024
LIC9099 (FAS) - (06/04)
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