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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600539
Report Date: 07/06/2023
Date Signed: 09/07/2023 09:40:44 AM

Document Has Been Signed on 09/07/2023 09:40 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: 145DATE:
07/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Julia Elias Medication SupervisorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Julia Elias Medication Supervisor and the reason for the visit was explained.

The purpose of the visit is in regards to the complaint issued on 08/13/2020 (COMPLAINT CONTROL NUMBER: 28-AS-20200813161238) and involving the incident in which Staff 1 (S1) physically assaulted Client (C1).

At today's visit, LPA Trueman interviewed Staff 2 (S2) and reviewed the video of the incident with S2. S2 confirmed that S1 was the individual on the video observed who threw multiple punches at C1. S2 also confirmed that S2 knew each individual as staff and client at the facility everyday and thus recognized them on the video.

Exit interview conducted and copy provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2023
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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