198600539-10-23-2025-28-AS-LHIS-DNMTH6-20251121134414

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 10/23/2025
Date Signed: 10/23/2025 01:08:43 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
10/15/2025 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20251015161403

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: 178	DATE:	10/23/2025
		UNANNOUNCED	TIME BEGAN:	09:21 AM
MET WITH:	Joyce Garcia, Administrator		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not prevent residents from engaging in a physical altercation.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit regarding the above allegation. LPA discussed the purpose of the visit with Administrator Joyce Garcia.

The investigation consisted of: A physical plant tour of the interior and exterior facility activity/common areas and dining room/kitchen area was conducted. A total of 5 staff and 14 residents were interviewed. Copies of incident report dated 10/15/25, staff and residents rosters, and copies of residents (R1- R3) file documents were obtained.

*See LIC 9099C for report continuation.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025

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 2

Control Number 28-AS-20251015161403

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: 10/23/2025

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

Allegation: Staff did not prevent residents from engaging in a physical altercation. The complaint alleges that on October 15, 2025, during breakfast meal time in the dining room resident (R2) got upset and threw a chair, threatened their life, and swung a cane at resident (R1). According to information obtained, R1 tried blocking the chair with their hand, but got hit in the torso area of the body. A total of 5 staff were interviewed. The majority of the 14 residents interviewed did not remember the incident. However, they stated that most of the time staff respond immediately to resident altercations. Pertaining to this specific incident, residents stated that staff immediately intervened and prevented injury. Staff interviews revealed that staff immediately intervene and tried to stop residents (R2 & R3) from attacking R1. Staff said that R2 & R3 falsely stated R1 spit on R3's food and tried to manhandle R3. Based on video surveillance footage review, the findings indicate that all three residents were eating breakfast in the dining room when R3 had an outburst and threw their plate at R1. Resident (R1) reacted but was not aggressive nor touched R2 & R3. Video footage confirms R2 threw a chair at R1. It also shows that there was staff supervision in the dining area, and staff immediately responded to the altercation. Based on record review, residents (R2 & R3) have history of hallucinations and impaired impulse control. The facility serves mentally disabled individuals, of which many have aggressive behaviors that are unforeseen. Facility staff handled the situation per facility procedures by separating the residents, restraining resident (R2), and reporting to the CCL Regional Office. Local law enforcement responded to the incident.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation are Unsubstantiated.

An exit interview was conducted and a copy of the report was discussed and provided to Joyce Garcia.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 2