198600539-5-4-2022-28-AS-MVAO-CHES8P-20220818133928

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 05/04/2022
Date Signed: 05/04/2022 04:20:28 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
02/24/2021 and conducted by Evaluator Jose Villalobos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210224102001

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: 159	DATE:	05/04/2022
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Administrator Yitzi Teichman		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Medication error - Staff are not following Dr. orders for medication
Staff not providing adequate food service
Facility’s intercom system is too loud.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent complaint investigation visit for the allegation(s) listed above. LPA met with Administrator Yitzi Teichman and the purpose of the visit was discussed.

The initial visit was conducted on 3/4/21 where LPA conducted a telephonic interview Staff #1 (S1) and toured facility. LPA requested medication documents from client #1s file for the last 2 months and copy of the facilities food menu.

On todays visit LPA Villalobos Interviews Clients #1-#10 (C1-C10) and Staff #2-#5 (S2-S5).

The investigation revealed the following; In regards to the allegation "Medication error - Staff are not following Dr. orders for medication" it was alleged that S2 attempted to overdose C1 by giving C1 extra medications. (5) of (5) staff interviewed denied the allegation. (10) of (10) Clients interviewed could not corroborate the allegations....
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: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

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-20210224102001

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: 05/04/2022

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

C1 could not recollect the incident on 2/24/22 to provide further details when interviewed. Review of files shows that there was an extra pill in the packet for the 2/24/22 AM Metformin medication that was discharged and not provided to client. No further information was provided showing that staff were not following medication orders. Although the allegation may have happened or is valid, there are not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED

In regards to the allegation, "Staff not providing adequate food service" it was alleged that the facility was serving not fully cooked bacon and salty food. (5) of (5) Staff interviewed denied the allegation. (9) of (10) clients interviewed could not corroborate the allegation. LPA observed the facilities food supply and did not observe health and safety concerns. Clients interviewed did not state bacon is undercooked or the food is too salty. Although the allegation may have happened or is valid, there are not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

In regards to the allegation, " Facility's intercom system is too loud" it was alleged that staff scream into the intercom system making it too loud. (5) of (5) Staff interviewed denied the allegation. (9) of (10) Clients could not corroborate the allegation. LPA did not observe clients having issues with the volume of the speakers while in care. C1 stated that sometimes the speakers have a demonic machinery sound to them and the screeching causes pain. Interviews do not show that there are issues with the volume of the intercoms in the facility. Although the allegation may have happened or is valid, there are not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED

No deficiencies 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: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2