336407734-8-10-2025-18-AS-EMAZ-DKQSX4-20250820141521

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336407734
Report Date: 08/10/2025
Date Signed: 08/10/2025 01:40:56 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
06/07/2022 and conducted by Evaluator Antonine Richard

COMPLAINT CONTROL NUMBER: 18-AS-20220607081916

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:	10:59 AM
MET WITH:	GENESSIS GARCIA		TIME COMPLETED:	02:37 PM

ALLEGATION(S):

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Resident sustained unexplained bruising while in care.

INVESTIGATION FINDINGS:

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On 08/10/2025, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent complaint visit to the facility above. LPA met with the Administrator Genessis Garcia, and the purpose of the visit was to deliver findings. On 08/09/2025, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced visit to the facility to initiate a complaint investigation into the allegation above. LPA met with the Administrators Vivien Rillo and Genessis Garcia, and the purpose of the visit was explained.

The investigation included the following: On 08/09/2025, LPA obtained the staff and residents roster (dated 07/01/2025), Resident #1's records, Face sheet. The investigation also reviewed the admission agreement (dated 02/09/2016), Physician Report (dated 05/31/2022), Preplacement Appraisal Information, Appraisal/Needs and Services Plan (dated 04/01/2023), Medication Administration Records.Unusual Incident/Injury report (dated 06/06/2022). The LPA conducted six staff and seven resident interviews and toured both the interior and exterior of the facility areas. LPA inspected six residents rooms. On 08/09/2025, LPA interviewed two witnesses.

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 3

Control Number 18-AS-20220607081916

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: Resident sustained unexplained injuries while in care

The complaint details indicate that resident #1 (R1) was transferred to Riverside Regional Medical Center on June 6, 2022, for labored breathing. During this visit, the hospital staff discovered various bruises on R1's left chest.

On August 9, 2025, the Licensing Program Analyst (LPA) interviewed Administrator #1 (A1), who denied the allegations. A1 explained that R1 sometimes becomes agitated due to medication side effects.

On the same day, the LPA interviewed five staff members (S1-S5), all of whom also denied the allegations. They emphasized that they treat all clients with respect and dignity and would never mistreat any residents in their care.

Additionally, the LPA spoke with six residents (R2-R7) on August 9, 2025. All of them denied the allegations and stated that the staff provide care and assistance with their daily activities. And never mistreated them.

On August 8, 2025, the LPA interviewed two witnesses (W1-W2), both of whom also denied the allegations. They reported observing R1 when agitated and noted that R1 had been hitting R1's chest. The witnesses affirmed that the facility staff are always caring and take good care of R1.

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 3

Control Number 18-AS-20220607081916

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 08/09/2025, LPA record review of the Medication prescribed list found that R1 was taking four medications, with their side effects being anger, hostility, Mild skin rash, hives, bruising, itchy skin, and weight loss. LPA was not able to interview Resident #1 due to R1 passed away on 05/29/2025.

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)

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