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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 11/08/2022
Date Signed: 11/08/2022 12:34:28 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
11/01/2022 and conducted by Evaluator Angelica Rea
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221101141548
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: 166DATE:
11/08/2022
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Andrew De Vern, Assistant Administrator TIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Facility staff mismanaged resident's medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angelica Rea conducted a visit in response to the above allegation. On today's visit, LPA met with Assistant Administrator Andrew De Vern, who assisted with the visit.

The investigation consisted of the following: Interview(s) Assistant Administrator, Staff #1 -Staff #2, Resident #2- Resident #7, Review of resident #1's file, and Review of resident #1's medication. Regarding the allegation that facility staff mismanaged resident #1's medication, Facility staff interviewed denied the allegation. Staff stated that resident #1 is medication compliant. Staff stated that resident #1 rarely refuses her medication, and when she does, it is documented. LPA reviewed Resident #1's medication and Medication Administration Record, and observed that Resident #1's medication has been administered as prescribed until 10/31/2022, when resident #1 was hospitalized. Resident #1 has not returned to the facility at the time of this visit. Residents interviewed were unable to corroborate the allegation. Residents interviewed stated that they are receiving their medication as prescribed and do not have any problems with staff mismanaging their medication.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022
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-20221101141548
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: 11/08/2022
NARRATIVE
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Based on LPA's observations and interviews, investigation revealed: 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.

No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted, and a copy of report was provided to Assistant Administrator, Andrew De Vera.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2