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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 08/06/2024
Date Signed: 08/06/2024 01:35:13 PM

Substantiated


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
07/24/2024 and conducted by Evaluator Erik Zaragoza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240724142311
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:
08/06/2024
UNANNOUNCEDTIME BEGAN:
08:28 AM
MET WITH:Tony Olmos - AdministratorTIME COMPLETED:
01:50 PM
ALLEGATION(S):
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Facility in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Erik Zaragoza conducted a subsequent complaint visit to investigate the allegation listed above. LPA met with Tony Olmos, Administrator for the facility, and explained the purpose of the visit.

The investigation consisted of the following: During the initial visit conducted on 7/30/2024, LPA Erik Zaragoza obtained the FACE Sheets, Physician's Reports, Pre-Placement Appraisals, and Needs and Services plans for Clients #1 - 2 (C1 - C2), obtained the staff and client rosters for the facility, toured the facility including twelve (12) separate client bedrooms, and also interviewed Clients #1 - 14 (C1 - C14), and also Staff #1 - 4 (S1 - S5). During today's visit, LPA interviewed Staff #6 (S6) and delivered findings for the investigation.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
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
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
07/24/2024 and conducted by Evaluator Erik Zaragoza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240724142311

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:
08/06/2024
UNANNOUNCEDTIME BEGAN:
08:28 AM
MET WITH:Tony Olmos - AdministratorTIME COMPLETED:
01:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility not providing a safe environment for client
INVESTIGATION FINDINGS:
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4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Erik Zaragoza conducted a subsequent complaint visit to investigate the allegation listed above. LPA met with Tony Olmos, Administrator for the facility, and explained the purpose of the visit.

The investigation consisted of the following: During the initial visit conducted on 7/30/2024, LPA Erik Zaragoza obtained the FACE Sheets, Physician's Reports, Pre-Placement Appraisals, and Needs and Services plans for Clients #1 - 2 (C1 - C2), obtained the staff and client rosters for the facility, toured the facility including twelve (12) separate client bedrooms, and also interviewed Clients #1 - 14 (C1 - C14), and also Staff #1 - 4 (S1 - S5). During today's visit, LPA interviewed Staff #6 (S6) and delivered findings for the investigation.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20240724142311
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: 08/06/2024
NARRATIVE
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The investigation revealed the following: In regards to the allegation that the "Facility is not providing a safe environment for client," it is alleged that C1 was being threatened by C2, and was fearful that C2 would hit them and reported this to the facility staff, however the staff were not doing anything to address the situation. During interviews with the clients, thirteen (13) out of fourteen (14) interviewed did not corroborate the allegation. During an interview with C1 they explained that staff assisted in moving C2 to a separate room, and since then there have been no issues with them being threatened and they feel the facility is a safe environment. Another client interviewed explained that the staff try their best to supervisor the clients to ensure that the environment of the facility is safe. During interviews with the staff, none of them corroborated the allegation that they have not been fostering a safe environment for the clients. One staff interviewed stated that they looked into an allegation that C2 was threatening C1 after C1 brought this to their attention, and they reviewed surveillance footage for the facility involving the two, however it revealed that C2 was talking to themselves and not threatening C1. Another staff interviewed stated that C2 was moved in response to C1's allegations to prevent any further potential tension between the two, and that the safety of the residents are always prioritized. During the tour of the facility, LPA observed no health and safety concerns in the facility.

Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported 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 allegation is UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20240724142311
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: 08/06/2024
NARRATIVE
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The investigation revealed the following: In regards to the allegation that "Facility is in disrepair," it was alleged that in room 109 of the facility, there is a hole underneath the sink through which rodents may potentially enter the room, and also that the room's blinds on the sliding door was in disrepair. During interviews with the clients, ten (10) out of fourteen (14) corroborated that there were parts of their room that were in disrepair. One client interviewed stated that their shower is not working, and that their toilet often does not flush properly. Another client interviewed explained that their toilet was broken, that they were missing a cupboard on their drawer, and that the drawer under their sink was broken. During interviews with the staff, two (2) out of six corroborated that some rooms in the facility were in disrepair. One staff interviewed confirmed that one of the sink faucets in a client bedroom is in need of being replace. Another staff interviewed confirmed that the blinds to one of the client bedrooms needs to be replaced. During the physical plant tour of the facility, LPA observed that the blinds in room #109 fall off immediately when touched, the shower in room #12A is broken and does not produce water, in room #206 the sink's faucet is in disrepair, room #21 had drawers missing from the cabinets and the sink drawer was broken, a washing machine on the second floor was not functioning, and one of the elevators to the facility was not operational. The facility has begun repairs on the sink in room #206, the facility's washer, and also on the main elevator for the facility.

Based on LPAs interviews conducted with the clients and staff, the preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 1 are being cited on the attached LIC9099D.

Exit interview held and a copy of the report and appeal rights was provided to the house manager Precious Brown.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20240724142311
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2024
Section Cited
CCR
80087(a)
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(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This regulation is not met as evidenced by:
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Administrator is to ensure that the facility is in good repair at all times. Facility to repair damages observed on this visit by POC due date. Pictures to be sent to LPA as proof and if needed a POC visit will be conducted.
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Based on observation, LPA determined that rooms #12A, 109, 21, 206, were in a state of disrepair, which poses a potential health and safety risk to clients 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: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5