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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600539
Report Date: 04/30/2024
Date Signed: 04/30/2024 10:11:15 AM

Document Has Been Signed on 04/30/2024 10:11 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
CCLD Regional Office, 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: DATE:
04/30/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH:Assistant Administrator Andrew De VeraTIME VISIT/
INSPECTION COMPLETED:
10:25 AM
NARRATIVE
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On 4/30/2024 at 8:35 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced subsequent investigation, control number 28-AS-20230717113356 and a Case management visit to deliver findings on the investigation conducted by DSS Investigation Branch (IB) investigator Jose Santana. Unpon arrival LPA met with Assistant Administrator Andrew De Vera and the purpose of the visit was discussed.

During the investigation it was found that the facility was negligent in supervision and allowed clients to possess or use drugs at the facility. The Investigation revealed that C1 has had on going issues since 2019 with drug addiction. The facility staff has admitted to seeing signs of C1 being under the influence. C1 also admitted to using drugs within the facility a week prior to interview with the IB investigator. On 9/29/2023 staff found a blue straw with white residue in C1’s wallet. C1 stated that it was crystal Methamphetamine’s obtained from another client. After review of C1’s file it was revealed that C1 received one warning in 2019.

Pursuant to Title 22 code of regulations, the following deficiencies were cited (refer to LIC 809-D): Exit Interview Conducted with Assistant Administrator / Appeal Rights Provided / A Copy of the Report Issued.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2024
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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Document Has Been Signed on 04/30/2024 10:11 AM - It Cannot Be Edited


Created By: Jewel Baptiste On 04/19/2024 at 02:02 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: 04/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
05/28/2024
Section Cited
HSC
1569.312(e)

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§1569.312 Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (e)Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being.

This requirement was not met as evidence by:
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The facility will ensure to provide adequate assistance to residents involved in illegal activities. The facility will provide training to staff on how to assist clients suspected of using drugs. A copy of the training and attendance log is due to the LPA by POC due date.
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Based on interviews and file review the facility allowed the residents to possess illegal drugs, which is a potential health, safety, or personal rights risk to persons 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:Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:
DATE: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024


LIC809 (FAS) - (06/04)
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