198600539-1-22-2026-28-AS-RORN-DQQP7G-20260127100356

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 01/22/2026
Date Signed: 01/22/2026 10:53:03 AM

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
07/23/2025 and conducted by Evaluator Erik Zaragoza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250723133744

FACILITY NAME:	PICO RIVERA GARDENS		FACILITY NUMBER:	198600539
ADMINISTRATOR:	JOYCE GARCIA		FACILITY TYPE:	735
ADDRESS:	6525 ROSEMEAD BLVD.		TELEPHONE:	(562) 949-8489
CITY:	PICO RIVERA	STATE: CA	ZIP CODE:	90660
CAPACITY:	185	CENSUS: 180	DATE:	01/22/2026
		UNANNOUNCED	TIME BEGAN:	09:32 AM
MET WITH:	Joyce Garcia - Administrator		TIME COMPLETED:	10:50 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff changed clients healthcare provider without clients permission

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

***This report supersedes report dated on 12/12/2025. The reason the report is being superseded is because additional information needs to be added to the report, and the deficiency cited needs to be corrected. All other findings remain the same.***

Licensing Program Analysts (LPA) Erik Zaragoza conducted a subsequent unannounced complaint visit to investigate the allegation listed above. LPA met with Administrator Joyce Garcia and Med Tech Supervisor Julia Elias and explained the purpose of the visit.

The investigation consisted of the following: On 7/31/2025, LPA Zaragoza interviewed Clients #1 - 16 (C1 - C16), Staff #1 - 4 (S1 - S4), obtained the staff and client rosters, and also obtained the FACE Sheets, physician's reports, and appraisals for C1 - C3. Since the initial visit, LPA obtained the Request for primcary care provider (PCP) Change Forms for Clients #17 - 19 (C17 - C19) from the administrator. During today's visit, LPA is delivering the findings of the investigation.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026

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-20250723133744

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: 01/22/2026

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: In regards to the allegation that "Facility staff changed clients healthcare provider without clients permission," it is alleged that at least three (3) clients have had their medical provider changed to the in-house facility medical provider without their permission. During interviews with the clients, five (5) out of sixteen (16) interviewed corroborated the allegation. One of the clients interviewed stated that their primary doctor had been changed to the in-house facility provider, and they had no idea how or why the change was made. Another client interviewed stated that their primary provider was also changed to the in-house facility provider, that they had no idea why this was the case, and they believe it was probably the facility staff that made the change. During interviews with staff none of them corroborated the allegation. One staff member explained that they utilize PCP Change forms that are signed by the client and sent to the in-house physician to process the PCP change. Another staff member stated that sometimes they complete the PCP change over the phone with the client's health insurance after the client provides consent to the insurance for the staff member to speak on their behalf. C1, C2, and C3 were identified in the complaint as having had their PCP changed without their consent and corroborated the allegation, and the facility was not able to provide any documentation that describes why the change was made. C13 and and C16 were not identified as potential victims, however they also corroborated the allegation and the facility was not able to provide any documentation providing explaining why their PCP was changed. The facility was able to provide documentation known as "Request for PCP/PPG Change Forms" for C17 - C19, however none of these clients were identified as possible victims in the original complaint report as having had their PCP changed without their permission.

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

Exit interview was held and a copy of the report along with the appeal rights were provided and will be emailed to the administrator.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 28-AS-20250723133744

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: 01/22/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 02/06/2026 Section Cited CCR 80072(a)(9)	1 2 3 4 5 6 7	(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (9) To receive or reject medical care, or health-related services, except for (...) clients for whom a guardian, conservator, or other legal authority has been appointed. This regulation is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator is to ensure that clients are made fully aware of the reason for their PCP changes moving forward. Administrator is to create a written plan on how the facility will document the consent of PCP changes for clients and the reasons for them, and submit it to licensing agency
	8 9 10 11 12 13 14	Based on staff/client interviews and a review of client records, LPA determined that facility staff changed changed their PCP without proof of consent for 5 out of 16 clients (C1, C2, C3, C13, and C16) which poses a potential health and safety threat to clients in care.	8 9 10 11 12 13 14	prior to implementation.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3