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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600539
Report Date: 07/07/2022
Date Signed: 07/07/2022 05:22:30 PM

Document Has Been Signed on 07/07/2022 05:22 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
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: 169DATE:
07/07/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:23 PM
MET WITH:Fabiola Padilla, Med-TechTIME COMPLETED:
05:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza generated this Case Management - Deficiencies report in conjunction with complaint control # 28-AS-20220705084756 pertaining to observations made during the kitchen inspection. The purpose of the visit was explained to Med-Tech Fabiola Padilla. Supervisor Andrew De Vera assisted with the inspection.

Observations:
  • The kitchen refrigerator temperature was 62 degrees instead of a minimum of 41 degrees per state law temperature requirements.

  • The right stove has 6 burners, of which 3 burners were not working properly.

  • Seven (7) out of 10 burners on the left stove do not work when the knob is turned on.

  • Two ovens are not operable.

  • There was gas odor in the kitchen. The Gas Company was called and visited the facility today.

  • Six (6) out of the 16 stove burners had flame without being turned on. Staff stated they have been this way for over 1 year.


See LIC 809D for deficiencies cited.


An exit interview was conducted and a copy of the report and appeal rights were issued to Fabiola Padilla.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2022
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 07/07/2022 05:22 PM - It Cannot Be Edited


Created By: Noemi Galarza On 07/07/2022 at 04:24 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: 07/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/08/2022
Section Cited
CCR
80087(a)

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Buildings and Grounds. 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 was not met evidenced by:
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Facility shall submit proof that the stoves, refrigerator, and freezer were checked and repaired by the gas company and appliance service company. Submit a written plan.

POC is due tommorow.
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Based on observation during the kitchen physical plant inspection, the refrigerator temperature was 62 degrees, instead of a minimum of 41 degrees, there was gas odor, and stove burners, and oven were not opering properly; which poses and immediate health and safety risk to persons in care and staff.
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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:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2022


LIC809 (FAS) - (06/04)
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