198600539-9-2-2022-28-AS-RORN-CJVKDH-20221004074845

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 09/02/2022
Date Signed: 09/02/2022 05:44:48 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
08/31/2022 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20220831083408

FACILITY NAME:	PICO RIVERA GARDENS		FACILITY NUMBER:	198600539
ADMINISTRATOR:	MEIR SHAUL YITZI TEICHMAN		FACILITY TYPE:	735
ADDRESS:	6525 ROSEMEAD BLVD.		TELEPHONE:	(562) 949-8489
CITY:	PICO RIVERA	STATE: CA	ZIP CODE:	90660
CAPACITY:	185	CENSUS: 166	DATE:	09/02/2022
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Andrew De Vera, Administrator assistant		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Resident was hit by another resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bonnie Tao conducted an unannounced initial 10-Day complaint investigation regarding the above allegations. LPA explained the purpose of today's visit to Andrew De-Vera, Administrator assistant, who assisted with this visit.

The investigation consisted of interviews with staff from staff #1 to staff#4, and residents from resident #1 to resident#10, and review of resident #1 and resident #2 files. The following documents were reviewed and obtained: Incident report dated 08/28/22, Face Sheets of C1 and C2, Appraisal / Needs and services plans of C1 and C2, Psychiatric evaluation of C2, and Physician Reports of C1 and C2.

The investigation revealed the allegation of “resident was hit by another resident in care,” it was alleged that client#1 punched client#2 in the head when they encountered each other at the facility lobby.
(-contined in LIC 9099C-)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220831083408

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: 09/02/2022

NARRATIVE

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According to client interviews, two (2) out of ten (10) clients stated C1 acted in a confrontational manner towards C2, punched in C2’s head and C2 thrown onto the ground. Per client interviews, no client witnessed the incident when that happened. Eight (8) out of ten (10) clients were not corroborated with the allegation. No previous physical altercations between C1 and C2 have occurred. Ten (10) out of ten (10) clients stated staff would intervene when clients had an altercation. Ten (10) out of ten (10) clients stated they feel safe residing at the facility.

Four (4) out of the 4 staff interviewed would respond to clients’ altercation immediately. Only S2 witnessed C1 punched C2. S2 immediately went to the lobby area after hearing a noise and intervened right away. None of other staff interviewed had observed the incident when it occurred. Per the Administrator, there has been no prior incident involving C1 and C2. This was an isolated incident. C1 received an one to one discussion from Administrator to prevent this incident from happening again. C2 said C2 had forgiven C1. Therefore, facility staff could not have done anything different to prevent the incident from happening.

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 conducted with Administrator Assistant, Andrew De-Versa. A copy of the report was issued.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022

LIC9099 (FAS) - (06/04)

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