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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 05/28/2024
Date Signed: 05/28/2024 03:22:20 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
08/23/2023 and conducted by Evaluator Sanjay Vaid
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230823113613
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: 137DATE:
05/28/2024
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Administrator, Tony OlmosTIME COMPLETED:
03:25 PM
ALLEGATION(S):
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Staff do not have the required training
INVESTIGATION FINDINGS:
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Licensing Program Analyst(s) (LPA) Sanjay Vaid and Jose Villalobos conducted a subsequent complaint visit for the allegation above. LPA's met with administrator Tony Olmos and the purpose of the visit was discussed.

On 08/25/2023 LPA Villalobos interviewed two (2) staff and one(1) client, collected and reviewed documents of staff and client files. As of now, LPAs have collected copies of the staff and client roster, a total of (26) staff files to review criminal record clearances and first aid/CPR documentation, interviewed staff #1-#5 (S1-S5) and client #1 (C1). The investigation revealed the following:

Regarding the allegation:Staff do not have the required training. It is alleged that staff are working in the facility without first aid/CPR certificates. (7) of (7) staff interviewed have denied this. (12) of (12) clients have no knowledge of hiring and training practices and could not corroborate the allegation...
Continued on 9099C..
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
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 5
Control Number 28-AS-20230823113613
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PICO RIVERA GARDENS
FACILITY NUMBER: 198600539
VISIT DATE: 05/28/2024
NARRATIVE
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Interviews with staff revealed that new hires must complete 2 weeks of training and pass test to be able to work in the medication room. Staff explained that first aid/ CPR certification is part of the training needed. Record review of twenty-six (26) staff files revealed that S4 did not have First Aid/CPR certification in their file. Facility staff was unable to provide LPA's with First Aid/CPR training certifications for S4. Staff interviews state that S4 worked at the facility anywhere from 1 day to 2 months at the facility providing clients assistance with medications. This shows that S4 did not have required first aid/CPR training prior to providing direct care and supervision to clients in care.

Based on the interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED

California Code of Regulations, Title 22, Division 6 and Chapter 8 was cited. See LIC 9099D.

An exit interview was conducted. Appeals rights were discussed. A copy of this report along with the appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
08/23/2023 and conducted by Evaluator Sanjay Vaid
COMPLAINT CONTROL NUMBER: 28-AS-20230823113613

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: 137DATE:
05/28/2024
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Administrator, Tony OlmosTIME COMPLETED:
03:25 PM
ALLEGATION(S):
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Staff are not criminally record cleared
INVESTIGATION FINDINGS:
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***This report supersedes the previous complaint report dated 04/09/24. The reason it’s being superseded is to provide additional information. The findings have changed due to additional information received, the complaint will be unsubstaniated***

Licensing Program Analyst(s) (LPA) Sanjay Vaid and Jose Villalobos conducted a subsequent complaint visit for the allegation above. LPA's met with administrator Tony Olmos and the purpose of the visit was discussed.

On 08/25/2023 LPA Villalobos interviewed two (2) staff and one(1) client, collected and reviewed documents of staff and client files. As of now, LPAs have collected copies of the staff and client roster, a total of (26) staff files to review criminal record clearances and first aid/CPR documentation, interviewed staff #1-#5 (S1-S5) and client #1 (C1). The investigation revealed the following:

Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20230823113613
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PICO RIVERA GARDENS
FACILITY NUMBER: 198600539
VISIT DATE: 05/28/2024
NARRATIVE
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Regarding the allegation: "Staff are not criminally record cleared." It is alleged that staff are working in the facility without background clearance. (5) of (5) Staff interviewed denied the allegation. (1) of (1) Client interviewed could not corroborate the allegation. On 04/09/24, LPA's Vaid and Reyes took copies of the Staff/Resident rosters, interviewed S#1 and reviewed files for Staff #2-Staff#3 (S2-S3) . LPA's did not observe S#2 and S#3 criminally cleared and associated to work in the facility. S#4 checked with the Care Provider Management Bureau regarding staff S#2 and S#3 for Criminal Background Clearance. Per S#4, both staff were cleared, however, a error was made during the live scan process, therefore the both staff did not get associated to the facility. S2 and S3 have been criminally record cleared since 12/13/23 as noted on their DOJ Response letter. While conducting further file reviews, LPAs reviewed a total of twenty six (26) Staff files and observed all staff to be criminally record cleared and associated. Staff currently on roster are all cleared.

Based upon records review and interviews conducted, the findings indicate that, 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 conducted and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20230823113613
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PICO RIVERA GARDENS
FACILITY NUMBER: 198600539
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/28/2024
Section Cited
CCR
80075(f)
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Reporting Requirements (f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.
The requirement is not met as evidence by:
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Currently all staff presently working have First Aid/CPR, S4 no longer works at the facility; therefore, First Aid/CPR is not required for S4. Deficiency is cleared on todays visit.
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Facility failed ensure S4 had First Aid/CPR training which poses a potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5