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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600539
Report Date: 11/15/2022
Date Signed: 11/15/2022 02:10:15 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
11/09/2022 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221109164522
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: 163DATE:
11/15/2022
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Administrator Yitzi TeichmanTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Resident was assaulted by another resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced complaint visit for the allegation above. LPA met with Administrator Yitzi Teichman and the purpose of the visit was discussed.

The following was conducted on todays visit, LPA interviewed Staff #1-#5 (S1-S5) and Clients #1-#15 (C1-C15). LPA toured the physical plant. LPA collected and reviewed documents from C1 and C2's file as well as the facility staff roster and client roster.

The investigation revealed the following: In regards to the allegations " Resident was assaulted by another resident" it was alleged that C1 was assaulted by another client of the facility. (5) of (5) Staff interviewed denied the allegation. (15) of (15 ) clients interviewed could not corroborate the allegation. Interviews do not show that C1 has gotten into any physical or verbal altercations with other clients in the facility. C1 denied being assaulted by any other client in the facility...

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: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022
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-20221109164522
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: 11/15/2022
NARRATIVE
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 Review of incident reports do not show altercations between C1 and any other client of the facility. Reports reviewed on file were dated for 10/9/22 and 5/4/22. LPA was not provided with dates to when C1 was assaulted by another client of the facility or if there were any witnesses. Based on the interviews conducted and files reviewed, there was not enough supportive evidence to concur with the reported allegation. 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 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: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2