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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336407734
Report Date: 09/24/2024
Date Signed: 09/24/2024 03:27:32 PM


Document Has Been Signed on 09/24/2024 03:27 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:PICO DE LOROFACILITY NUMBER:
336407734
ADMINISTRATOR:VIVIEN RILLO/EFREN RILLOFACILITY TYPE:
740
ADDRESS:620 NORTH PERRIS BLVDTELEPHONE:
(951) 943-8081
CITY:PERRISSTATE: CAZIP CODE:
92571
CAPACITY:43CENSUS: 39DATE:
09/24/2024
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
02:22 PM
MET WITH:MED-TEC, MARIA VALENCIATIME COMPLETED:
03:35 PM
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On September 24, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility to conduct an unannounced collateral visit. LPA conducted interviews for an unrelated matter to the facility. The collateral visit was conducted to make observations, interviews and records reviews pertaining to another matter.

The LPA met with Lead Med-Tech, Maria Valencia introduced herself and stated the purpose of the visit. LPA Mixson toured the facility along, with Med-Tech and made observations relating to another matter altogether and interviewed Resident Number 1 (R1) who is also the (Reporting Party), from the previous matter.

There were no health and safety concerns or issues observed during the time of this visit. The facility was clean and well maintained there were no obstructions to the inside or outside passageways. LPA Mixson reviewed several resident files and made observations to the other matter being investigated.

LPA Mixson reviewed the daily notes written pertaining to Resident Number 1 (R1). LPA Mixson requested and received pertinent documentation pertaining to R1.

An exit interview was conducted a copy of this report was discussed and given to Med-Tech, Maria Valencia
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
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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