<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600539
Report Date: 08/18/2023
Date Signed: 08/21/2023 10:18:13 AM

Document Has Been Signed on 08/21/2023 10:18 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:
08/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Supervisor Julia EliasTIME COMPLETED:
02:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced visit at the facility for the purpose of conducting the required annual inspection using the CARE Tool. LPA met with Supervisor Julia Elias and and the purpose of the visit was discussed
Structure/Physical Plant:
The facility is a large 2 story building with (93) client rooms licensed to serve up to (185) clients of which ten (10) may be ambulatory. The overall structure is described as 2 connected buildings known as Building A and Building B. Building A houses the main lobby, medication room, kitchen, dining room and two laundry rooms. Building B consists of a quiet room, TV room, an activity room, 2 laundry rooms and 3 offices. The (93) rooms are among the first and second floor of each building. Each client room has their own bathroom. Based on the client population being served and the census, at the time of this visit, the facility is operating within the conditions and limitations specified on the license. LPA toured the physical plant and observed the following rooms: #7, #8, #10, #11, #12, #26, #30, #41, #103, #108, #204, #205, #211, and #214Accommodations: Adequate accommodations observed throughout facility. Hallway and Doorways: Free and clean of obstruction and debris. Client Rooms: All bedrooms are equipped with: overhead lighting, chair, night stand, lamp in addition to overhead lighting, large drawer, and closet space. Bathrooms: All bathrooms have a working toilet, wash basin, shower, grab bars and nonskid mats. Linens & Hygiene Supplies: Required linen/supplies observed. Emergency Phone Numbers, Exit Plan & Menu: Facility has a working phone landline. There is a phone for Client use.Food Service: All food and adequate utensils such as, dishes, cups, bowls and plates observed. Smoke Detectors & Fire Extinguishers: Fire and CO2 detectors are connected to Fire Panel and last serviced 4/23/23. Fire Extinguishers observed throughout Toxins: Locked/stored for staff use only. Hot Water Temperature: Measured between 105 -115 degrees all around the facility. Medications, First-Aid Kit & Book: Medications centrally stored and inaccessible to clients. First aid kit observed. Postings:Postings observed.Residents & Staff Files: LPA reviewed fourteen (14) Client medications records and files , as well as ten (10) Staff Files . Emergency Disaster Plan, Plan of Operation and Infection Control observed.
Inspection tool completed and, per Title 22, deficiency is being cited. See 809-D page. Exit Interview conducted and a copy of this report and appeal rights discussed and provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 08/21/2023 10:18 AM - It Cannot Be Edited


Created By: Jose Villalobos On 08/18/2023 at 01:24 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PICO RIVERA GARDENS
FACILITY NUMBER: 198600539

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on obervation LPA observed the licensee did not comply with the section cited above as Room #30 had broken bathroom wall behind the toilet and towards the shower tub and Room #103 had a hole through the bathroom door larger than a tennis ball, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/01/2023
Plan of Correction
1
2
3
4
Facility to repair damages observed on this visit by POC due date. Pictures to be sent to LPA as proof and if needed a POC visit will be conducted.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Fernando Fierros
LICENSING EVALUATOR NAME:Jose Villalobos
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2