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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600539
Report Date: 07/30/2024
Date Signed: 07/30/2024 04:22:58 PM

Document Has Been Signed on 07/30/2024 04:22 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
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:
07/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:24 AM
MET WITH:Julia Elias - TIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Compliance and Regulatory Enforcement (CARE) Tools. LPAs explained the purpose of the visit to Julia Elias, Medication Technician supervisor for the facility, and explained the purpose of the visit. Administrator Tony Olmos arrived shortly thereafter. There are currently one hundred and thirty-seven (137) clients residing within the facility.

LPA toured the facility including twelve (12) client bedrooms, the kitchen, the various washing rooms of the facility, as well as the medication room. Knives and chemicals and cleaning supplies were kept locked and inaccessible to the clients. There were multiple outdoor shaded areas available for clients to use.

LPA also reviewed seven (7) client physician orders along with their Medications Administration Records (MARs), and seven (7) client files. LPA also interviewed five (5) clients as part of the annual inspection.

The kitchen was inspected along with the food preparation area, and these areas were observed to be clean and sanitary. A seven (7) day supply of non-perishable food and two (2) day supply of perishable foods were observed in the kitchen.



Due to time constraints, LPA was not able to complete the Annual Inspection at this time and will be returning to complete it at a later date. Exit interview held and a copy of this report was provided to Andrew De Vera.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE: DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2024
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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