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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 07/13/2022
Date Signed: 07/13/2022 02:22:16 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
06/16/2021 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210616132238
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: 164DATE:
07/13/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:S-1TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility staff did not practice proper hygiene while distributing medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit. LPA met with S-1 and discussed the purpose of today's visit.

LPA Irra conducted the initial 10-day investigation visit on 06/23/2021. During the course of this investigation, LPA Irra interviewed the Facility Administrator, Staff #2 (S-2), Staff #3 (S-3) and Staff #4 (S-4) LPA left a voice mail message for S-1 for a return call. S-1 did not return LPA’s call. LPA also left a voice mail message for Client #1 (C-1) for a return call which C-1 did not return any calls. LPA obtained documentation relevant to this investigation. LPA Irra also conducted telephone interviews with Client #2 through Client #11 (C-2 through C-11).

Refer to LIC 9099C for the continuation of this report.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
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-20210616132238
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: 07/13/2022
NARRATIVE
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Allegation: Facility staff did not practice proper hygiene while distributing medication. During this investigation, LPA Irra interviewed the Facility Administrator, S-2 through S-4 and interviewed C-2 through C-11. Staff interviews revealed that staff practice appropriate hand hygiene (use hand sanitizer and/or disposable gloves) while administrating medication. Interviewed staff indicated they have not observed any staff not practicing appropriate hand hygiene. Interviewed staff indicated they have not received any complaints/concerns from anyone in regards to staff not practicing appropriate hand hygiene. Interviewed Staff also indicated they have not observed any staff in the medication room being inappropriate with anyone (including within staff members). Client interviews revealed that staff practice appropriate hygiene while distributing medication. Interviewed clients indicated they observe staff using hand sanitizer and/or gloves at all times while medication is being distributed. Interviewed clients indicated they do not have any concerns in the current hygiene practice. Interviewed clients indicated they have not heard anyone complaining about staff’s hygiene while distributing medication. Client interviews also revealed that clients have not observed any staff in the medication room being inappropriate with anyone (including within staff members). Staff and client interviews do not corroborate this allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated

NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2