336407734-8-10-2025-18-AS-EMAZ-DKQTD3-20250820143740

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336407734
Report Date: 08/10/2025
Date Signed: 08/10/2025 01:46:52 PM

Unsubstantiated

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
01/03/2023 and conducted by Evaluator Antonine Richard

COMPLAINT CONTROL NUMBER: 18-AS-20230103131101

FACILITY NAME:	PICO DE LORO		FACILITY NUMBER:	336407734
ADMINISTRATOR:	VIVIEN RILLO/EFREN RILLO		FACILITY TYPE:	740
ADDRESS:	620 NORTH PERRIS BLVD		TELEPHONE:	(951) 943-8081
CITY:	PERRIS	STATE: CA	ZIP CODE:	92571
CAPACITY:	45	CENSUS: 38	DATE:	08/10/2025
		UNANNOUNCED	TIME BEGAN:	08:07 AM
MET WITH:	GENESSIS GARCIA		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff did not prevent resident from being injured by another resident.
Facility staff did not ensure resident's furniture was in good repair.

INVESTIGATION FINDINGS:

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On 08/10/25, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent complaints investigation into the allegations above to deliver findings. LPA met with the staff, and the purpose of the visit was explained. LPA toured the facility and inspected six residents' rooms.

The investigation consisted of the following: On July 29, 2025, LPA obtained the staff and resident roster (dated July 14, 2025), Resident #1's records, and the Face sheet. The investigation also reviewed the admission agreement (dated December 14, 2022), Physician Report (dated December 14, 2022), Preplacement Appraisal Information, Appraisal/Needs and Services Plan (dated December 26, 2022), Medication Administration Records, and Unusual Incident/Injury Reports (dated December 18, 2022, January 11, 2023, and February 21, 2023). On 07/29/25, LPA obtained the Riverside County Sheriff’s Department Report Case# PE223520058, dated 12/19/22. The Riverside University Health System R1 visit occurred on 12/18/22. The LPA conducted interviews with five staff members and six residents. The LPA interviewed the Administrators, Vivien Rillo and Efren Rillo.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2025

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 4

Control Number 18-AS-20230103131101

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
	VISIT DATE: 08/10/2025

NARRATIVE

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Allegation #1: Staff did not prevent the resident from being injured by another resident.

The complaint alleges that the staff did not prevent the resident from being injured by another resident, which resulted in the residents being taken to the hospital.

On August 9, 2025, between 09:00 AM and 03:30 PM, the LPA interviewed Administrators #1- 1(A1-A1), who denied the allegations. A1s stated that they ensured all residents received adequate supervision and provided the necessary training to the facility staff to care for the residents effectively.

During the same time frame, the LPA interviewed five staff members (S1, S2, S3, S4, S5). All five staff members denied the allegations and asserted that they consistently provided supervised care for Resident #1 (R1) daily.

Later, on August 9, 2025, between 10:30 AM and 03:30 PM, the LPA interviewed six residents (R2, R3, R4, R5, R6, R7). All six residents denied the allegations and stated that the staff took good care of them. They also stated that when residents fight among themselves, the staff promptly separates them.

Records reviewed from R1’s medical discharge papers from Riverside University Health System indicated that R1 fell on December 18, 2022, but sustained an abrasion to the head and a black eye on the left side. On 08/29/25, the LPA obtained the Riverside County Sheriff’s Department Report Case# PE223520058, dated 12/19/22, which indicated that R1 was not assaulted but had fallen.

Report Continued LIC9099C

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 18-AS-20230103131101

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
	VISIT DATE: 08/10/2025

NARRATIVE

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On August 09, 2025, records reviewed showed that staff completed training in Fall Prevention and Safety Protocols, Personal Rights for residents. Staff also learned how to prevent residents from fighting or arguing by redirecting them.

The LPA also reviewed R1's Appraisal/Needs and Services Plan, which did not indicate that R1 was considered a fall risk and showed that R1 did not need assistance walking. The LPA was unable to interview Resident #1 because R1 passed away on 05/29/25. Records reviewed also indicated the facility send an unusual incident/injury report to Licensing depart on 12/23/22 about the incident.

Based on the LPA observations, interviews, and record reviews, the preponderance of evidence has not been met. Although the allegation may have happened or is valid, there is insufficient evidence to prove whether the alleged violation did or did not take place; therefore, the allegation is unsubstantiated.

Allegation #2: Facility did not ensure resident's furniture was in good repair.

The complaint alleges that the facility staff did not ensure the resident's furniture was in good repair and that food and utilities were functioning properly. On 08/09/2025, LPA interviewed the Administrators #1-#1 (A1-A1), who denied the allegation and stated that the furniture in the resident rooms is in good condition. On the same day, 08/09/2025, LPA interviewed five staff members #1-5 (S1-S5), all of whom denied the allegations that the furniture was in disrepair and that the utilities were not functioning.

Report Continued on LIC9099C

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 18-AS-20230103131101

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
	VISIT DATE: 08/10/2025

NARRATIVE

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On the same day, 08/09/2025, LPA interviewed six residents #2-7 (R2-R7). All six residents denied the allegations that the furniture in their rooms was in disrepair, that they lacked food, and that their facilities' utilities were not working. They also stated that they have not noticed the furniture falling apart. On 08/10/2025, LPA toured the facility and inspected six residents' rooms #1, #8, #10, #12, #14, and #20; all inspected rooms were in good condition, with no tears, damaged furniture, or broken items. The lights in the resident rooms were working properly. On the same day, 08/10/2025, LPA observed the residents having lunch. The food served was an ample portion. LPA was unable to interview Resident #1 because R1 had left the facility on 03/10/2023,and passed away in 2025.

Based on records review, interviews, and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegation is Unsubstantiated.

No deficiencies were cited.

An exit interview was conducted, and a copy of this report was provided to the Administrator Genessis Garcia.

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 4