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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600539
Report Date: 01/27/2023
Date Signed: 01/30/2023 08:25:10 AM

Document Has Been Signed on 01/30/2023 08:25 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 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: 165DATE:
01/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:46 PM
MET WITH: Assistant Administrator Andrew De VeraTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Jose Villalobos and Kevin Gaines conducted a case management visit for incident report dated 8/20/22. LPA met with Assistant Administrator Andrew De Vera and explained the purpose of the visit.

On todays visit, LPA Villalobos toured of the physical plant. LPA observed the food supply, observed that the medications were locked and inaccessible to clients. No bodies of water were observed in the facility and no passageways were blocked. LPA collected a copy of the staff and client roster as well as documents from Client #1 (C1) file. Incident Report dated 8/20/22 states that a trespasser entered the facility and attached C1 in their room. LPA observed client room #51 was clean and in good repair. Facility was informed that a later visit may be conducted regarding the incident report received.


No deficiency's are cited on todays visit and a copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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