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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600539
Report Date: 11/30/2023
Date Signed: 11/30/2023 03:50:15 PM

Document Has Been Signed on 11/30/2023 03:50 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:
11/30/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH: Interm-Administrator Andrew DeVera.TIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Ashley Calderon made an unannounced visit to address a separate incident at the time of the visit. LPA upon arrival was greeted by Marketer Christina Vasquez and later was met with Interm-Administrator Andrew DeVera.

LPA Calderon conducted a tour in room Room 2,9,15,16,18,19,23 and 24 with Christina Vasquez. During the tour LPA observed the following:

At 10:10am Room 2 was observed: bathroom were observed to have feces smeared on toilet and floor, floor was wet and smeared with feces, dirt , mud. Beds were observed with dirty bedsheets, used paper plate cups,plates and utensils piled up and scatted on the floor, two residents living in the room.

At 10:28am Room 19 was observed: unoccupied room, stains on wall, cigarette buds and debris found on floor, and bathroom had debris on counter and floor and black toilet water was observed. LPA found a resident sleeping in the recliner chair. Per interview with Interm-Administrator Andrew DeVera stated room 19 is vacant and resident who was found sleeping on the recliner was moved to room 9 from room 19 to conduct room repairs. Resident shouldn't have been in Room 19 as that is not their room.

At 10:27am Room 23 was observed: Metal bed frame above closet, glass door shattered, bed mattress on floor, dresser and a mattress up against a wall. Sliding door leads to a facility parking lot that is not closed off to the public and per interview with Interm-Administrator parking lot gate is closed around 6pm.

At 10:26am Room 24: unoccupied room found with sliding doors that does not have a latch to close and keep secure, Staff Christina Vasquez tried to lock the door but was unable to lock door due to broken latch/ lock. LPA observed belongings, trash, and empty alcohol cans in room and bathroom left on counters and floor.

LPA Calderon will return to the facility at a later time due to insufficient time, a copy of this report will be emailed to Interm-Administrator Andrew DeVera.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
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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