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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 07/18/2023
Date Signed: 07/18/2023 01:54:47 PM

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
07/17/2023 and conducted by Evaluator Jewel Baptiste
COMPLAINT CONTROL NUMBER: 28-AS-20230717113356

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: 140DATE:
07/18/2023
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Administrator Andrew Devra TIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Facility has bed bugs
INVESTIGATION FINDINGS:
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On 7/18/2023 at 8:50 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced complaint investigation visit for the allegations above. LPA met with Staff Julia Elias and the purpose of the visit was discussed. Administrator Andrew Devra joined the visit at 9:17 a.m.

The investigation consisted of: LPA Baptiste interviewed the Administrator and Staff #1-#3 (S1-S3) and clients #3-#13 (C3-C13). C1 was not available for interview. LPA collected copies of Dewey pest controll bill dated 7/1/2023, Staff roster, Client Roster and took photos of bed bugs in room #7. LPA reviewed C1 and C2's file and collected copies of their admission agreement, needs and services plan, Identification and Emergency Information, Preplacement appraisal information, Appraisal needs and services plan, and medications list. LPA additionally conducted a tour of the physical plant.
Report continued on 9099c
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20230717113356
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: 07/18/2023
NARRATIVE
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The investigation revealed the following:

Regarding the allegation "Facility has bed bugs" it was alleged that the facility continually has bed bugs. During the tour LPA took photos of bed bugs in room #7. Upon arrival LPA overheard a client informing staff they have a bug problem in their room. The administrator confirmed the allegation, stating the facility is using Orkin to treat the problem. 2 out of 3 staff stated they have not seen bed bugs in the client’s rooms but have heard clients report it to the facility. 1 out of 3 staff has seen bed bugs at the facility. 3 out of 3 staff confirmed the facility is being treated once a month. 6 out of 11 clients has not seen bed bugs but are aware of it being in other client’s rooms. 4 out 11 clients confirmed the allegation. 1 out of 11 has seen ticks.

Based on LPA observation, interviews and file review, the preponderance of evidence standard has been met, therefore the above allegations is found to be SUBSTANTIATED. California Code of Regulation, Title 22 are being cited on the attached LIC9099D.



Exit Interview Conducted with administrator/ Appeal Rights Provided / A Copy of the Report Issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20230717113356
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: 07/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/18/2023
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation; (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidence by:
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Licensee will ensure that the facilty is free of bed bugs at all times and send proof to LPA by POC due date.
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Based on observation, interviews, and documents reviewed licensee did not ensure to keep facility free of bed bugs. LPA Baptiste took a photo of bed bugs in room #7. Administrator confirmed the facility has bed bugs, which poses an potential health, safety, or personal rights risk to persons incare.
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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.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6