336407734-7-24-2025-18-AS-JARA-DJVTQK-20250724145605

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336407734
Report Date: 07/24/2025
Date Signed: 07/24/2025 02:56:32 PM

Document Has Been Signed on 07/24/2025 02:56 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	PICO DE LORO		FACILITY NUMBER:	336407734
ADMINISTRATOR/ DIRECTOR:	VIVIEN RILLO/EFREN RILLO		FACILITY TYPE:	740
ADDRESS:	620 NORTH PERRIS BLVD		TELEPHONE:	(951) 943-8081
CITY:	PERRIS	STATE: CA	ZIP CODE:	92571
CAPACITY: 45		CENSUS: 38	DATE:	07/24/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Administrator, Yamberly Genesis Garcia		TIME VISIT/ INSPECTION COMPLETED:	03:00 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) Janira Arreola conducted an unannounced required annual visit. LPA met with Administrator, Yamberly Genesis Garcia, and Licensee Efren Rilo who were informed of the purpose of the visit. The facility is a one story building with resident bedrooms, bathrooms, shower rooms, staff office, activity spaces, and outdoor spaces. The facility does not have a pool or firearms. The facility is a residential care facility for the elderly ages 59 and above, approved for (45) non ambulatory resident, all of which may be bedridden, and approved for locked perimeter. Physical Plant: Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility's outdoor area was observed to be free of hazards. Laundry equipment was observed to be in good working condition. LPA observed locked dangerous items, such as centrally stored medication, sharps, and cleaning supplies. Documentation was provided showing carbon monoxide, smoke detectors and fire extinguishers were charged and tested July of 2025 and are operational. LPA observed the facility signaling system is operation and location in resident bedrooms and bathrooms. Hot water temperature was recorded at 105F in a resident bathroom. The facility has cleaning supplies to conduct regular cleaning of the facility, and personal hygiene supplies for the residents. Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 7- day non perishable and 2-day perishable food items. The menus are posted and resident's prescribed diets and allergies are accessible to kitchen staff.

NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Janira Arreola
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/24/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PICO DE LORO	FACILITY NUMBER: 336407734
	VISIT DATE: 07/24/2025

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LPA reviewed the staff schedule for staff coverage. LPA observed staff rounding and active care and supervision of residents. The current administrator has a current certificate. Required postings are found in the facility. LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing last fire drill conducted on 7/2025.

Record Review and Resident/Staff Files: LPA reviewed (3) staff files which possess all required documents such as criminal record clearances and training including CPR and First aide training. (5) resident files were reviewed and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All resident medication was locked in a medication room. LPA reviewed (3) resident medication lists and found medication accounted for.

No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was reviewed and provided.

*LPA was off site from 11:38am to 1:38pm in order to prepare today's report.

NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Janira Arreola
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/24/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025

LIC809 (FAS) - (06/04)

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