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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600539
Report Date: 06/06/2022
Date Signed: 06/06/2022 01:44:55 PM

Document Has Been Signed on 06/06/2022 01:44 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: DATE:
06/06/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Julia Elias, Medication SupervisorTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit and explained the purpose of this visit to Staff. During the visit today, LPA conducted a tour of the facility with the assistance of the maintenance staff. The air conditioners cannot be adjusted individually by the clients. Per the maintenance staff, the air thermostats in Building A are located inside some clients' rooms in which that thermostat controls several adjacent rooms. For Building B, the thermostats are located outside of the rooms in the hallways which also controls several rooms. The thermostats are locked and set on auto at 70 degrees according to the staff. The clients do not have access to change the temperature of the room. During the tour, LPA checked all the thermostats and observed the following:

* Thermostat between room #109 and #110 was off and needed to be plugged in before it worked again.
* Thermostat between room #210 - 212 was off and maintenance staff turned it back on to auto.
* Thermostat by the t.v room in side B needs the battery replaced.
* The air conditioner in the first floor activity/ t.v room was not working properly and minimal cool air was coming out of vents.

The deficiency was issued on the LIC809D. An exit interview was conducted and a copy of this report, LIC809D, and appeal rights were provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2022
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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Document Has Been Signed on 06/06/2022 01:44 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 06/06/2022 at 01:13 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: 06/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/13/2022
Section Cited
CCR
80088(a)

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80088 Furniture, Fixtures, Equipment, and Supplies (a) A comfortable temperature for clients shall be maintained at all areas.
This requirement is not met as evidenced by:
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The licensee shall check all thermostats frequently to ensure that they are on and working properly. Licensee shall submit a plan to ensure the rooms' air conditioners are on and clients are comfortable. The POC shall be submitted to LPA by 6/13/22.
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Based on observation, LPA saw some thermostats to be off which poses a potential health, safety, and personal rights risk to clients in care.
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2022


LIC809 (FAS) - (06/04)
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