198600539-4-11-2024-28-AS-RORN-D4EQQM-20240417122233

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 04/11/2024
Date Signed: 04/11/2024 03:04:06 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
11/16/2023 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231116171728

FACILITY NAME:	PICO RIVERA GARDENS		FACILITY NUMBER:	198600539
ADMINISTRATOR:	MEIR SHAUL YITZI TEICHMAN		FACILITY TYPE:	735
ADDRESS:	6525 ROSEMEAD BLVD.		TELEPHONE:	(562) 949-8489
CITY:	PICO RIVERA	STATE: CA	ZIP CODE:	90660
CAPACITY:	185	CENSUS: 145	DATE:	04/11/2024
		ANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Tony Olmos Administrator		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Questionable Death
Staff are not adequately trained

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Tony Olmos Administrator and explained the reason for the visit.
The purpose of the visit is to deliver findings from the original complaint dated 11/16/2023.
The initial visit was a Health and Safety Check conducted on 11/20/2023 and included the following: LPA toured the physical plant. LPA observed rooms 7, 12 A, 204 and 216. Water temperatures tested within Title 22 requirements. LPA did not observe any path obstructions or health and safety hazards. Sufficient food supply was observed and all toxins and sharps were observed to be stored and locked away properly, inaccessible to client's in care.
At today's visit Staff S1's and Staff S2's file was reviewed and training documents were submitted,
Investigation was conducted by the Investigations Branch (IB) and completed 03/25/2024 for allegations
Questionable Death and Staff are not adequately trained
Investigation consisted of interviews with facility staff, clients, and review of documentation
which includes County of Los Angeles Department of Medical Examiner Case #2023-15631, Los Angeles

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

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-20231116171728

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: 04/11/2024

NARRATIVE

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Sheriffs Department (LASD), Death Certificate for Client C1 and documentation from the file of Client C1 which included Unusual Incident Injury Report, and Appraisal Needs and Services Plan.
In regards to the allegation Questionable Death based on file review, interviews conducted , documentation from other agencies, and information it was revealed that on 11/13/2023, Client C1 did not respond to his medication call. Staff S 1 conducted a medication room check on C1 and found him to be unresponsive, and dialed 911. While conducting chest compressions, S 1 stated C1's body was warm and cold, with no pulse. When EMS, Los Angeles Fire Department (LAFD) along with Los Angeles Sheriff’s Department (LASD) arrived at the facility, they took over the scene, and pronounced C1 dead upon arrival. According to the County of Los Angeles, Department Medical Examiner Case#: 2023-15631 Examination Protocol for C1, the cause of death (COD) “death was due to fentanyl and methamphetamine intoxication. Manner of death was an accident.” Based on the interviews and supporting documents, there is insufficient evidence to support the allegation of Questionable Death; therefore, the allegation is unsubstantiated.
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 allegation is UNSUBSTANTIATED.
In regards to the allegation Staff are not adequately trained, based on file review, interviews and information gathered it was revealed that Staff S1 completed on August 28,2023 CPR/ AED/ First Aid
and Staff S 2 completed CPR/ AED/ First Aid on November 5, 2023 and they are valid for 2 years.
Based on Los Angeles County's Sheriffs Report it states that Staff S1 discovered C 1 unresponsive and not breathing and called 911 and was directed to perform CPR which was done for 10 minutes.
It was revealed that Client C1 did not respond to his medication call and Staff S1 and Staff S2 conducted a medication room check on Client C 1 and promptly dialed 911. While conducting chest compressions, Staff S 1 stated Client C1's body was warm and cold, with no pulse. When emergency medical services (EMS), along with the Los Angeles Fire Department (LASD) and Los Angeles Sheriff’s Department (LASD) arrived at the facility, they took over the scene, and pronounced Client C1 dead upon arrival.
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.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC9099 (FAS) - (06/04)

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