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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 06/29/2022
Date Signed: 06/29/2022 05:12:12 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
06/24/2022 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220624134140
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: 166DATE:
06/29/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Supervisor Andrew DeveraTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Resident hit another resident while in care.
Facility is unsanitary.
Facility food service is inadequate.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Supervisor Andrew Devera and explained the purpose of the visit.

The following was conducted on todays visit, LPA interviewed Staff #1-#5 (S1-S5) and Clients #1-#12 (C1-C12). LPA was unable to interview Client #13 (C13) as they were not in the facility. LPA toured the physical plant. LPA observed the facility food supply. LPA collected documents from C1 and C13's file as well as a client and staff roster. LPA also collected incident report documents related to the complaint and facility Dietitian report.

The investigation revealed the following: Regarding the allegation "Resident hit another resident while in care." it was alleged that C13 hit C1 in the back of the head while in care. (5) of (5) staff interviewed denied the allegation. (11) of (12) clients interviewed could not corroborate the allegations. Interviews show that C1 was by the med room on 6/21/22 when C13 randomly swung his arms, hitting C1 in his head...

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: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022
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-20220624134140
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: 06/29/2022
NARRATIVE
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Staff immediately separated the clients and called the police as well as began notifying responsible parties. The incident was unprovoked as there was no discussion between C1 and C13 prior to the incident. Staff followed protocol as the incident occurred. C1 stated that staff did help and controlled the situation. LPA also reviewed report documenting the incident and call to police. Based on the interviews conducted and files reviewed, there was not enough supportive evidence to concur with the reported allegation. 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 the allegation is UNSUBSTANTIATED.

Regarding the allegation "Facility is unsanitary." it was alleged that the facility is dirty and has urine on the floor. (5) of (5) staff interviewed denied the allegation. (11) of (12) clients interviewed could not corroborate the allegations. Interviews show that the hallways of the facility do get dirty in between meals and snack times because clients will walk out with juices and coffee that spills often. Interviews also show that staff clean the hallways at the start of each shift and in between each meal time because of the constant cleaning required. There were no interviews that show clients urinate around the halls or common rooms of the facility. LPA observed custodial staff clean the facility throughout the time of the visit. Based on the interviews conducted and observations, there was not enough supportive evidence to concur with the reported allegation. 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 the allegation is UNSUBSTANTIATED.

Regarding the allegation "Facility food service is inadequate." it was alleged that the facility food is bad. (5) of (5) staff interviewed denied the allegation. (9) of (12) clients interviewed could not corroborate the allegations. LPA was not provided with information as to how the food is bad. Interviews show that clients would prefer tastier meals with larger portions but did not overall state the food is bad. LPA reviewed the food menu. LPA requested and obtained documentation for the facility’s dietitian consultant. Documentation revealed facility’s consultant is a Registered Dietitian (RD) and last visit date was 5/31/22. The facility scored 72% sanitation grade when inspected by the RD. LPA toured the facility kitchen and food supply and did not observe any deficiencies at the time of the visit. Based on the interviews conducted and observations, there was not enough supportive evidence to concur with the reported allegation. 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 the allegation is UNSUBSTANTIATED.

Exit Interview was conducted with Andrew Devera 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: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2