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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600539
Report Date: 06/08/2023
Date Signed: 06/08/2023 09:19:16 AM

Document Has Been Signed on 06/08/2023 09:19 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
GREATER LA AC/SC, 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:
06/08/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Andrew De Vera - Assistant AdministratorTIME COMPLETED:
09:32 AM
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Licensing Program Analyst (LPA) Mora conducted an unannounced plan of correction (POC) visit to follow up on deficiencies noted on 05/15/23. LPA met with Andrew De Vera - (Assistant Administrator) and explained the reason for the visit.

On 5/15/23 LPA Mora conducted a complaint investigation visit and cited the following deficiency:
Section CCR 85088(d) Fixtures, Furniture, Equipment and Supplies - On 5/15/23, LPA observed that the facility had 2 out of 6 washers and 5 out of 6 dryers that are were not working. On 6/08/22, LPA Mora returned to the facility to delivered a report that supersedes the report dated 05/15/23 due to making corrections on the LIC 9099-D and during this visit LPA observed that all dryers and washers were working properly.

Exit interview was conducted with Andrew De Vera (Assistant Administrator) an a copy of this report was provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/08/2023
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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