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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 10/04/2021
Date Signed: 10/04/2021 04:08:31 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
07/27/2021 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210727092456
FACILITY NAME:PICO RIVERA GARDENSFACILITY NUMBER:
198600539
ADMINISTRATOR:MEIR SHAUL YITZI TEICHMANFACILITY TYPE:
735
ADDRESS:6525 ROSEMEAD BLVD.TELEPHONE:
(562) 949-8489
CITY:PICO RIVERASTATE: CAZIP CODE:
90660
CAPACITY:185CENSUS: 172DATE:
10/04/2021
UNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Supervisor Julia Elias TIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff is not providing a safe environment for resident's.
Resident has access to a knife.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
*** This report supersedes report dated 8/4/2021. Details were corrected and added to reflect information collected. No changes made to findings***

Licensing Program Analyst (LPA) Jose Villalobos initiated a subsequent complaint investigation for the allegation(s) listed above. Today’s complaint investigation was conducted with Supervisor Julia Elias and purpose of the visit was discussed.

investigation conducted on 8/4/21 consisted of the following: LPA Villalobos interviewed staff #1-#6 (S1-S6) and Clients #1-13 (C1-C13). LPA toured the physical plant. LPA also obtained and reviewed copies of the following documents in reference to C1 and C2; • Identification and Emergency Information • Appraisal/Needs and Services Plan • Pre-placement Appraisal Information • Physician's Report • Resident Roster • Staff Roster • Medication Records • Incident Report dated 7/12/21

Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021
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-20210727092456
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: 10/04/2021
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
*** This report supersedes report dated 8/4/2021. Details were corrected and added to reflect information collected. No changes made to findings***

The investigation revealed the following: In regards to the allegation "Staff is not providing a safe environment for resident's" it was alleged that staff allowed C2 to threaten and be a menace to clients in care. (6) of (6) staff interviewed denied the allegation. (11) of (13) clients interviewed could not corroborate the allegation. Interviews show that on 7/12/21 around 8:30am, C1 was yelling and insulting C2 in the hallways when C2 then brandished a nail filer and used it to threaten C1 to back off. Immediately staff arrived and separated the clients. Staff removed the item from C2's possession and police were called. LPA observed security footage of the incident and it showed staff intervene de-escalate the situation. Interviews show that S1 then took C2 outside to remove the item used to threaten C1. S1 also checked C2's backpack and did not find anything else. C2 then went to their room where C2 got into another altercation with roommate C3. C2 then pulled out a knife from somewhere in their room. Immediately staff heard the altercation and arrived to separate the clients. The knife was then removed from C2's possession. Staff conducted a room check and police arrived with C2's placement agency to place C2 in a 51/50. C2 was taken from the facility but returned back to the facility on 7/15/21 and has not had an incident since. C2 had not had an incident similar to this prior to the 7/12/21 incident. C2 stated that the items were all purchased outside of the facility when C2 goes out into the community. Based on interviews with staff and clients in care, the facility staff attempts to resolve situations as soon as they are aware of them. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore this allegation is unsubstantiated.

In regards to the allegation "Resident has access to a knife." it was alleged that staff allowed C2 to have a knife in the facility. (6) of (6) staff denied the allegation. (11) of (13) clients interviewed could not corroborate the allegation. Interview with C2 shows that the nail filer and knife confiscated from C2 were purchased at a dollar store outside of the facility. Facility staff were not aware that C2 owned the items and once they were aware, they confiscated them. Review of C2 file shows that C2 is able to go out of the facility unassisted. Interviews with staff corroborate this information. Based on interviews with staff and clients in care, the facility staff was not aware that C2 had the items mentioned but did confiscate them once they were aware. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore this allegation is unsubstantiated.

No deficiencies are being cited on todays visit. Exit Interview was conducted and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021
LIC9099 (FAS) - (06/04)
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