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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600539
Report Date: 06/18/2024
Date Signed: 06/18/2024 11:46:07 AM

Document Has Been Signed on 06/18/2024 11:46 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/
DIRECTOR:
SANTOS DOMINGUEZFACILITY TYPE:
735
ADDRESS:6525 ROSEMEAD BLVD.TELEPHONE:
(562) 949-8489
CITY:PICO RIVERASTATE: CAZIP CODE:
90660
CAPACITY: 185CENSUS: 137DATE:
06/18/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:02 AM
MET WITH:Julia Elias - Med Tech SupervisorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Erik Zaragoza conducted a case management visit to follow-up on an initial case management visit that was conducted on 4/30/2024. LPA was met by Julia Elias, Med Tech supervisor for the facility, and was granted entrance. Administrator Tony Olmos arrived shortly thereafter. The initial visit was conducted in response to the death of Client #1 (C1), who passed away on 4/26/2024.

During the initial visit conducted on 4/30/2024, the facility staff provided LPA C1's Physician's Report, FACE Sheet, Appraisal/Needs and Services Plan, and their Medication Administration Records (MARs) for the past 3 months. Administrator Tony Olmos also explained that he will email LPA a copy of the death certificate for C1 once it becomes available. LPA also toured the bedroom of C1 and found no concerns.

Since the initial visit, the death certificate for C1 was provided to LPA by Tony Olmos from the County of Los Angeles Department of Public Health, and the cause of death was cardiac arrest. The medical conditions which contributed to the immediate cause of death were congestive heart failure and morbid obesity. The death has been determined to not be suspicious.

At this time, no further action is required and no citations will be issued. Exit interview held and a copy of this report was provided.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024
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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