<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600539
Report Date: 07/21/2023
Date Signed: 07/21/2023 02:28:35 PM

Document Has Been Signed on 07/21/2023 02:28 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:MEIR SHAUL YITZI TEICHMANFACILITY TYPE:
735
ADDRESS:6525 ROSEMEAD BLVD.TELEPHONE:
(562) 949-8489
CITY:PICO RIVERASTATE: CAZIP CODE:
90660
CAPACITY: 185CENSUS: 150DATE:
07/21/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:21 PM
MET WITH:Andrew DeVera - Assistant AdministratorTIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Bennette Pena initiated a Case Management- Deficiencies after it was discovered during the course of the investigation for complaint control # 28-AS-20230719151400 that the facility did not submit an incident report (SIR) regarding an incident that happened between (2) clients on 7/18/2023 to CCL.

A citation was issued.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit on 7/21/2023 is documented on 809D.

Exit interview held and a copy of the report along with appeal rights were provided to Andrew DeVera, Assistant Administrator.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 07/21/2023 02:28 PM - It Cannot Be Edited


Created By: Bennette Pena On 07/21/2023 at 01:23 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: 07/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2023
Section Cited
CCR
80061(b)(1)(E)

1
2
3
4
5
6
7
Reporting Requirements. (b) Upon the occurrence ..... (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days.... : (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
1
2
3
4
5
6
7
Assistant Administrator agreed to submit a written plan of correction. In addition, an incident report must be submitted to CCL by POC due date.
8
9
10
11
12
13
14
This requirement was not met evidenced by:
On July 18, 2023 Clients #1-#2 (C1 & C2) allegedly engaged in a physical altercation that was not reported to CCL which poses a potential health and safety risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2