198600539-10-4-2021-28-AS-RORN-CK4P92-20221011110626

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 10/04/2021
Date Signed: 10/04/2021 04:09:19 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
02/03/2021 and conducted by Evaluator Jose Villalobos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210203083402

FACILITY NAME:	PICO RIVERA GARDENS		FACILITY NUMBER:	198600539
ADMINISTRATOR:	DOMINGUEZ, SANTOS		FACILITY TYPE:	735
ADDRESS:	6525 ROSEMEAD BLVD.		TELEPHONE:	(562) 949-8489
CITY:	PICO RIVERA	STATE: CA	ZIP CODE:	90660
CAPACITY:	185	CENSUS: 172	DATE:	10/04/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Supervisor Julia Elias		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Staff gave resident a damaged medication
Lack of supervision resulting in a resident harassing another resident in care.

INVESTIGATION FINDINGS:

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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.

Initial Visit conducted on 2/11/21 consisted of: LPA conducted a telephone interview with staff #1-#4 (S1-S4), and clients #1-#8 (C1-C8). LPA also observed the medications for clients #1 #2 and #9 (C9). LPA requested client #1 and #2's facesheet and medication chart.

Investigation revealed the following; In regards to the allegation, "Staff gave resident a damaged medication" it was alleged that on 2/2/21 C1 received their medication with the inside powder of the capsule removed from inside and placed over the top of the capsule. (4) of (4) Staff denied the allegation. (7) of (8) clients interviewed could not corroborate the allegation.

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)

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Control Number 28-AS-20210203083402

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

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Review of C1's medication chart does not note damaged medication or medication refusal. Interviews with C1 show that C1 did not have staff exchange the medication and took the medication. Interviews with Staff show that it would not have been possible for the inside powder to be put over the top of the capsule without damaging the capsule itself. 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, "Lack of supervision resulting in a resident harassing another resident in care." it was alleged that C2 harasses C1 by following C1 around and yelling at C1. (4) of (4) staff interviewed denied the allegation. (7) of (8) clients interviewed could not corroborate the allegation. Interviews with staff show that they have not witnessed C2 harass C1 in the facility. Interviews with C2 denies following and harassing C1 in the facility. 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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