198600539-10-20-2022-28-AS-RORN-CQSTSB-20230411145853

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 10/20/2022
Date Signed: 10/20/2022 03:53:39 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
01/28/2021 and conducted by Evaluator Jose Villalobos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210128104722

FACILITY NAME:	PICO RIVERA GARDENS		FACILITY NUMBER:	198600539
ADMINISTRATOR:	DOMINGUEZ, SANTOS		FACILITY TYPE:	735
ADDRESS:	6525 ROSEMEAD BLVD.		TELEPHONE:	(562) 949-8489
CITY:	PICO RIVERA	STATE: CA	ZIP CODE:	90660
CAPACITY:	185	CENSUS: 170	DATE:	10/20/2022
		UNANNOUNCED	TIME BEGAN:	01:31 PM
MET WITH:	Assistant Administrator Andrew De Vera		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff did not provide assistance to resident.
Staff not providing laundry service to residents.
Food service is inadequate.
Staff did not safeguard resident's personal items.
Staff do not keep facility free of trash.
Staff did not give resident access to a telephone.

INVESTIGATION FINDINGS:

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nLicensing Program Analyst (LPA) Jose Villalobos conducted a subsequent visit for the allegation(s) listed above. LPA met with Assistant Administrator Andrew De Vera and the purpose of the visit was discussed.

Initial Visit conducted on 2/4/21 consisted of the following: LPA conducted a telephone interview with staff #1-#2 (S1-S2), and clients #1-#2 (C1-C2). LPA also conducted a virtual tour of facility and observed the common areas, the kitchen, food supplies, and room #3 and room #4. LPA requested copies of Staff and Resident Rosters, and copies of client #1s file, copy of facility food menu for the month.

On todays visit, LPA Villalobos interviewed client #3-#16 (C3-C16) and staff #3-#6 (S3-S6). The investigation revealed the following:

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: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

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-20210128104722

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: 10/20/2022

NARRATIVE

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In regards to the allegation "Staff did not provide assistance to resident" it was alleged that water from another clients room entered C1's room and staff refused to assist in cleaning. (6) of (6) Staff interviewed denied the allegation. (15) of (16) Clients interviewed could not corroborate the allegation. Interviews with staff show that S2 personally assisted C1 clean the room when notified of water dripping into C1s bathroom from above. Interviews also showed that the water had leaked after a client upstairs from C1's room overflowed their bathtub. Once aware of the situation , interviews stated that staff assisted in cleaning the water up. During the initial virtual tour, LPA did not observe leaking water in C1's bedroom and no water on the floors. Based on interviews, 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 this allegation is unsubstantiated.

In regards to the allegation "Staff not providing laundry service to residents." it was alleged that because of covid-19 cases in the facility, the staff were not assisting clients with their laundry. (6) of (6) Staff interviewed denied the allegation. (15) of (16) Clients interviewed could not corroborate the allegation. interviews show that staff continued to wash clients clothes even when they were covid positive. At the time the facility covid outbreak , clients were asked to put their clothes in bags and leave them outside their door so staff would grab it and wash it for them. Interviews with clients and staff confirmed this information. LPA was not provided with proof that staff refused to provide laundry service to clients in care. Based on interviews, 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 this allegation is unsubstantiated.

In regards to the allegation "Food service is inadequate." it was alleged that the facility does not serve nutritional meals to clients. (6) of (6) Staff interviewed denied the allegation. (15) of (16) Clients interviewed could not corroborate the allegation. LPA toured the food storage and observed required amount of perishables and non-perishables. LPA observed kitchen audit completed 2/4/21 by the facilities Dietitian that gave a score of 87%. Interviews did not show that the meals are not nutritional. Based on interviews and observations, 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 this allegation is unsubstantiated.

Continued on LIC 9099-C

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20210128104722

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: 10/20/2022

NARRATIVE

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In regards to the allegation "Staff did not safeguard resident's personal items." it was alleged that C1 had gift cards stolen by other clients in the facility. (6) of (6) Staff interviewed denied the allegation. (15) of (16) Clients interviewed could not corroborate the allegation. LPA was not provided with proof that C1 owned gift cards or that gift cards were stolen. Interviews do not show that staff or other clients were aware C1 owned gift cards and that clients were stealing from C1. Based on interviews conducted, 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 this allegation is unsubstantiated.

In regards to the allegation "Staff do not keep facility free of trash." it was alleged that the staff do not clean the facility. (6) of (6) Staff interviewed denied the allegation. (15) of (16) Clients interviewed could not corroborate the allegation. LPA observed the hallways and common areas of the facility to be clean and in good repair. LPA did not observe blocked passage ways or trash in the common areas. Interviews show that staff clean the facility daily. Based on interviews conducted and observations, 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 this allegation is unsubstantiated

In regards to the allegation "Staff did not give resident access to a telephone." it was alleged that S3 and S4 did not allow C1 to use the facility phone on one occasion. (6) of (6) Staff interviewed denied the allegation. (15) of (16) Clients interviewed could not corroborate the allegation. Interviews with staff do not show that incident occurred. LPA was not provided with proof that the incident occurred. Interviews with clients did not show that staff do not allow clients to use the phone. LPA observed clients walk up the phone and use it freely at the time of this visit. LPA did not observe staff limiting clients. Based on interviews conducted and observations, 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 this allegation is unsubstantiated

Exit Interview conducted 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: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

LIC9099 (FAS) - (06/04)

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