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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 03/10/2022
Date Signed: 03/10/2022 04:46:06 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
04/06/2020 and conducted by Evaluator Nune Margaryan
COMPLAINT CONTROL NUMBER: 28-AS-20200406120538
FACILITY NAME:PICO RIVERA GARDENSFACILITY NUMBER:
198600539
ADMINISTRATOR:DOMINGUEZ, SANTOSFACILITY TYPE:
735
ADDRESS:6525 ROSEMEAD BLVD.TELEPHONE:
(562) 949-8489
CITY:PICO RIVERASTATE: CAZIP CODE:
90660
CAPACITY:185CENSUS: 160DATE:
03/10/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Yitzi Teichman
and Assistant Administrator Andrew De Vera
TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff spoke inappropriately to resident in care
Resident was not provided clean drink ware.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nune Margaryan conducted subsequent complaint visit for the allegations listed above. LPA met with Administrator Yitzi Teichman and explained the purpose of visit.

Initial visit conducted telephonically on 04/13/2020 by LPA Pat Rivas. LPA interviewed Administrator and 1 staff.
Today’s Investigation revealed the following; Obtained copies of clients roster, staff roster, Client #1 (C1's) Identification and Emergency Information/Face Sheet, Physician Report, Appraisal/Needs and Services Plan, and interviews with Administrator, Staff #1 – Staff # 5 (S1-S5), Client #1 – Client #16 (C1- C16).

Continue 9099C

Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
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-20200406120538
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: 03/10/2022
NARRATIVE
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Regarding the allegation that, “Staff spoke inappropriately to resident in care”, it was alleged that C1 was fighting and arguing with staff, playing games by ordering the food and then cancelling it. Also was alleged that staff interrupted C1 when client tried to talk with the friend.

Interview conducted with C1 denied those allegations. C1 indicated that staff did not say that client is playing games by ordering food. Stated staff did not interrupt C1's conversation with the friend. Administrator and staff interviewed denied the allegations. Facility provides the daily menu to the clients and also clients can choose something else from alternate menu if they want. Administrator stated that most of the time clients eat at the facility. Sometimes clients go out to eat or order food from outside. In the past during the early times of the pandemic, Administrator and staff help C1 and other clients to order food and they also stated that sometimes clients have ordered food and later cancelled it. In addition they also stated that the staff have not spoken inappropriately and they have not told clients that they are fighting and arguing with staff, playing games by ordering food. Staff treat the clients with respect. Interviewed clients denied the allegation. They stated that staff spoke appropriately to clients.

Regarding the allegation that, “Resident was not provided clean drink ware” it was alleged that Client #1 (C1) found hair on the rim of his coffee cup. Administrator and staff interviewed denied the allegation. They stated that residents always provided clean drink ware / dinnerware, disposable plates or cups. Clients interviewed were unable to corroborate the allegation. They stated that staff always serve drink or food with clean cups and plates.

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.


An exit interview was conducted, and a copy of this report was provided to the Assistant Administrator.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
LIC9099 (FAS) - (06/04)
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