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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 02/04/2025
Date Signed: 02/04/2025 11:16:11 AM

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
01/14/2025 and conducted by Evaluator Erik Zaragoza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250114084928
FACILITY NAME:PICO RIVERA GARDENSFACILITY NUMBER:
198600539
ADMINISTRATOR:JOYCE GARCIAFACILITY TYPE:
735
ADDRESS:6525 ROSEMEAD BLVD.TELEPHONE:
(562) 949-8489
CITY:PICO RIVERASTATE: CAZIP CODE:
90660
CAPACITY:185CENSUS: 150DATE:
02/04/2025
UNANNOUNCEDTIME BEGAN:
08:46 AM
MET WITH:Joyce Garcia - AdministratorTIME COMPLETED:
11:29 AM
ALLEGATION(S):
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Staff are contaminating food for clients in care
Facility staff did not provide adequate supervision
Facility staff did not dispense medications as prescribed
Staff did not treat resident with dignity and respect
Staff made inappropriate comments to residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Erik Zaragoza conducted a subsequent unannounced complaint visit to deliver findings on the allegations listed above. LPA met with Joyce Garcia, administrator for the facility, and explained the purpose of the visit.

The investigation consisted of the following: On the initial visit conducted on 1/21/2025, LPA interviewed Staff #1 - 4 (S1 - S4), interviewed Client #1 and Clients #3 - 15 (C1, C3 - C15), obtained copies of the staff and client rosters, reviewed the medication logs and medications for seven (7) different clients, reviewed photographic evidence of C1's meal, and also toured the kitchen during the preparation for lunchtime meals. LPA attempted to interview Client #2 (C2), however they were hospitalized at the time of the visit. During today's visit, LPA delivered the findings of 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: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
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 3
Control Number 28-AS-20250114084928
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: 02/04/2025
NARRATIVE
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The investigation revealed the following: In regards to the allegation that "Staff are contaminating food for clients in care," it is alleged that C1 was served a eggs and bagels that appeared to be contaminated with a clear translucent substance on them, and also found bits of bug legs in their food. During interviews with the clients, fourteen (14) out of fifteen (15) interviewed did not corroborate the allegation. One of the clients interviewed stated that they are satisfied with the food and that they have never witnessed any unusual substances on their meals. Another client interviewed stated the food is of good quality and there has never been any contaminants in their food. During interviews with the staff, none of them corroborated the allegation. LPA interviewed S3 the lead kitchen supervisor and stated that the kitchen staff always wear hairnet and gloves when preparing the meals to prevent contamination, and that no clients have brought to their attention that the food is contaminated. Another staff interviewed stated that there are no contaminants and no other problems with the food served by the facility .LPA toured the kitchen during the meal preparation for lunch on 1/21/2025 and did not observe any contaminants in the food during the preparation of the food, and staff were wearing hairnets and gloves when handling the food. Additionally S4 provided LPA a photograph of the translucent material on the bagel and eggs, and found that the eggs had melted cheese on them while the bagels had droplets of liquid on them that appeared to be olive oil.

In regards to the allegation that "Facility staff did not provide adequate supervision," it is alleged that C2 had gasoline poured on them after S2 broke into their room three (3) consecutive days in a row. During interviews with the clients, fourteen (14) out of fifteen (15) did not corroborate the allegation. One clients interviewed stated that they have never witnessed staff harming or physically abusing another client in the facility. Another client interviewed stated that they feel the staff adequately supervise the clients of the facility and have never witnessed any staff abusing the clients. During interviews with staff, none of them corroborated the allegation. During interviews with S2, they stated that they had never broken into C2's room or poured gasoline on them, and did not know why the allegation was made. Another staff interviewed stated C2 has never had gasoline poured on them, and was currently hospitalized for reasons separate than physical harm.
In regards to the allegation that "Facility Staff did not dispense medication as prescribed," it is alleged that C1 was not obtaining one of their medications as they should from the facility staff. During interviews with the clients, fourteen (14) out of fifteen (15) did not corroborate the allegation. One of the clients interviewed stated that their were no issues getting their medications as prescribed. Another client interviewed stated that everything was okay when obtaining their medications. During interviews with the staff, none of them corroborated the allegation. One staff interviewed stated that C1 does not have a prescription for the medication they are requesting, and C1 refuses to switch their primary doctor to the facility's doctor so they have not been able to obtain the physician's order for the medication.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20250114084928
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: 02/04/2025
NARRATIVE
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Another staff interviewed stated they have been attempting to schedule an appointment with C1's primary doctor and provide transportation as well to obtain the prescription, however C1 has been reluctant to see their doctor. During review of C1's physician orders, there was no prescription for the medication they are requesting. Review of the medications and medication logs for the other six (6) residents revealed that they were all receiving their medication as prescribed.

In regards to the allegation that "Staff did not treat resident with dignity and respect," it is alleged that S1 has ignored and spoken over C1 in conversations when C1 is bringing up their concerns. During interviews with the clients, thirteen (13) out of fifteen (15) did not corroborate the allegation. One client interviewed stated that both S1 and S4 are nice and have treated them and other clients with respect. Another client interviewed stated that all of the staff in the facility are respectful to the clients. During interviews with the staff, none of them corroborated the allegation. S1 stated there are times when C1 requests to speak, and S1 explains to C1 if they are busy and will speak with them later, however C1 has interpreted this to be disrespectful. Another staff interviewed stated that staff do listen to C1's concerns as well and that they have never been disrespectful towards C1 when doing so.

In regards to the allegation that "Staff made inappropriate comments to residents," it is alleged that S4 cursed at C1, and that staff over the intercom system have told clients at night that no one care about them. During interviews with clients, fourteen (14) out of fifteen (15) denied the allegation. One client stated they have never heard staff say anything mean to the clients. Another client interviewed stated they have not heard any staff curse at anyone in the facility. During interviews with staff, none of them corroborated the allegation. S4 stated that they have never cursed at C1 or any other client. All other staff have denied that S4 has cursed at clients or that staff have made inappropriate remarks to clients over the intercom system.

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 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 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: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3