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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600539
Report Date: 06/15/2023
Date Signed: 06/15/2023 03:32:08 PM

Document Has Been Signed on 06/15/2023 03:32 PM - 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: 147DATE:
06/15/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:46 PM
MET WITH:Assistant Administrator Andrew De VeraTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Jose Villalobos conducted and unannounced case management visit regarding death report received on 6/5/23. LPA met with Staff Andrew De Vera and the purpose of the visit was discussed.

Licensing received death report on 6/5/23 for Client #1 (C1). On todays visit, LPA interviewed Staff #1-#2 (S1-S2). LPA was informed that C1 went out the hospital on 5/11/23 due to pain and discomfort. C1 was then admitted to a skilled nursing facility on 5/19/23 instead of returning to the facility. The skilled nursing facility then transferred C1 back to a hospital on 5/27/23 where C1 passed away that day. C1 had a diagnosis of breast cancer that dates back to 2021 and refused to receive treatment. C1 did not pass away in the facility and was present in the facility since 5/11/23. LPA confirmed during review of C1's file.

During the visit LPA obtained staff, resident roster, C1s Identification and Emergency Information, physician’s report, needs and services plan, and medication log. During todays visit LPA conducted a health and safety check and toured the physical plant. LPA observed the food supply. LPA observed sharps, medications, and chemicals under lock. There were no health and safety concerns at the time of the visit.

Facility to obtain a copy of death certificate and provide to Licensing when available.

Exit interview was conducted and a hard copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2023
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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