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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 07/07/2022
Date Signed: 07/08/2022 11:04:59 AM

Substantiated


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
07/05/2022 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220705084756
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: 169DATE:
07/07/2022
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Meir Yitzi Teichman, AdministratorTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff serve contaminated foods to residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted an initial 10-Day complaint visit to investigate the above allegations.The purpose of the visit was discussed with Administrator Meir Yitzi Teichman. Supervisor Andrew De Vera assisted with the physical plant inspection.

The investigation consisted of: A physical tour of the facility, room 46, and kitchen was conducted. The intercom sound system was tested. The kitchen was inspected and lunch meal service was observed. Staff (S1-S9) and clients (C1-C16) were interviewed. Client (C1's) file documents [Identification and Emergency Information, Preplacement Appraisal, Physician Report, Psychiatric Notes, Appraisal Needs/Services Plan, monthly food menu [6/5/22 - 7/9/22], Medication Administration Records (June 2022 & July 2022), staff schedule, and client roster were obtained.
NOTE: There were deficiencies observed in the kitchen that are cited in a separate case management report.

See LIC 9099C for report continuation.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
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 3
Control Number 28-AS-20220705084756
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: 07/07/2022
NARRATIVE
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Allegation: Staff serve contaminated foods to residents. It is alleged that staff serve food to clients that has been touched and rejected by other clients in care, and that plastic and hairs have been observed food servings. Based on interviews conducted three (3) out of sixteen (16) clients stated they are served food contaminated food. Kitchen staff and other staff interviewed denied this allegation. They stated that client (C1) complains about all the food frequently and has episodes of paranoia that causes the resident to be overly suspicious about food served, staff, and other clients. The kitchen staff in question is not employed at the facility.

A tour of the kitchen was conducted, as well as observation of lunch service. No foreign substances were observed in food. However, during today's lunch service, three (3) clients reported to kitchen staff that the milk being served tasted sour and was spoiled. LPA inspected the refrigerator milk storage area. The majority of the milk cartons (24 gallons) had an expiration date of July 8, 2022. The food supply was not expired, but damaged food cans were observed in the storage areas. In addition, there were kitchen staffing shortages today and the maintenance staff (S9) assisted with kitchen responsibilities during lunch service. S9 does not have a food handling certificate. NOTE: Other deficiencies were observed and are cited in a case management report.

LPA observed the kitchen refrigerator was not within the minimum 41 degree state law temperature for perishable foods. The temperature was 62 degrees. Kitchen personnel confirmed the refrigerator temperature is not within the required temperature.

Based on interviews conducted and observations, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. Deficiency is cited. See LIC 9099D.

Exit interview was conducted with Med-Tech Fabiola Padilla. A copy of the report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20220705084756
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/08/2022
Section Cited
CCR
80076(a)(1)
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Food Services. In facilities providing meals to clients, the following shall apply: All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients... All food shall be selected, stored, prepared and served in a safe and healthful manner.
This requirement was not met evidenced by:
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Facility shall ensure the refrgerator and freezer temperatures are within normal limits, and all food items shall be stored in a healthful manner. Spoiled milk shall not be given to clients.

Submit a written plan stating how this was corrected, and proof that the refrigerator was serviced. POC is due tomorrow.
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Based on observation during lunch meal service 3 clients were given spolied milk, and the refrigerator temperature was not 41 Degrees or below. The temperature was 62 degrees. which poses and immediate health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3