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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336407734
Report Date: 05/15/2024
Date Signed: 05/15/2024 09:24:07 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/05/2024 and conducted by Evaluator Sara Martinez
COMPLAINT CONTROL NUMBER: 18-AS-20240305095021
FACILITY NAME:PICO DE LOROFACILITY NUMBER:
336407734
ADMINISTRATOR:VIVIEN RILLO/EFREN RILLOFACILITY TYPE:
740
ADDRESS:620 NORTH PERRIS BLVDTELEPHONE:
(951) 943-8081
CITY:PERRISSTATE: CAZIP CODE:
92571
CAPACITY:43CENSUS: 40DATE:
05/15/2024
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrative Assistant Yamberly Genesis GarciaTIME COMPLETED:
09:35 PM
ALLEGATION(S):
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Staff did not conduct a preadmissions assessment
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced visit to deliver findings regarding the allegation listed above. LPA was granted entry and met with Administrative Assistant Yamberly Genesis Garcia, who was Informed of the purpose of the visit.

Regarding the allegation “Staff did not conduct a preadmissions assessment”, it was alleged Administrator Efren Rillo did not conduct a preadmissions assessment for Resident One (R1) that reflects R1's level of care. R1 was admitted to the facility on 04/24/2014. R1's Resident Appraisal form was signed and dated on 04/25/2014 revealing prior to R1's admission, a determination of the prospective resident's suitability for admission and appraisal of R1's individual service needs, feeding, toileting, transferring, and grooming was not completed. Based on records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided to Garcia.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
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 18-AS-20240305095021
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PICO DE LORO
FACILITY NUMBER: 336407734
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/24/2024
Section Cited
CCR
87457(c)
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87457 Pre-Admission Appraisal – General (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs...with the admission ...This requirement has not been met as evidenced by:
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The licensee agreed to send a self certified statement stating that the licensee has read and reviewed the section cited here. This shall be sent to the LPA by the POC due date.
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Based on record review, the licensee did not comply with the section cited above completeing R1's preadmission appraisal prior to the resident being admitted to the facility which posed a potential health, safety or personal rights risk to persons in care.
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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.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
LIC9099 (FAS) - (06/04)
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