<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 05/13/2024
Date Signed: 05/13/2024 03:18:33 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
03/25/2024 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240325111548
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: 136DATE:
05/13/2024
UNANNOUNCEDTIME BEGAN:
08:02 AM
MET WITH:Administrator Tony OlmosTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not providing a good quality of food to residents in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
*This is a corrected verison of previously 9099 dated 4/23/2024. LPA Ramirez conducted additional interviews. No changes to findings. LPA Rammirez updated the number of clients interviews from 3 to 10.*
Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 04/23/2024 to deliver findings. 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- 10 interviews (C1 – C10), 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: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024
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-20240325111548
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: 05/13/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The investigation revealed the following. Regarding Allegation(s): Staff are not providing a good quality of food to residents in care - It is alleged staff are not providing good quality of food to residents in care. On 3/28/24, LPA Ramirez conducted physical plant tour, including kitchen area. LPA Ramirez examined perishables food in refrigerator and freezer. LPA Ramirez observed all appliances to be clean and in working condition. LPA Ramirez observed kitchen staff wearing hair nets and gloves while handling food. LPA Ramirez observe signage in the kitchen area reminding staff to discard any leftovers left in the refrigerator beyond 24 hours. LPA Ramirez observed weekly facility menu posted in dining room area. Facility menu was observed to be approved by Registered Dietitian, Linda Morita. Three (3) out of the three (3) staff interviewed denied this allegation. One (1) out of the ten (10) clients interviewed deny this allegation. 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: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2