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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191222631
Report Date: 10/12/2022
Date Signed: 10/12/2022 12:27:08 PM

Document Has Been Signed on 10/12/2022 12:27 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:NELVILLE GUEST HOMEFACILITY NUMBER:
191222631
ADMINISTRATOR:HERMINIA DELACRUZFACILITY TYPE:
735
ADDRESS:2005 E. ORANGE GROVE BLVD.TELEPHONE:
(626) 791-1170
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 4DATE:
10/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:49 AM
MET WITH:Administrator, Herminia Dela CruzTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced required-1 year inspection focusing on the Infection Control Domain. LPA Pena met with Administrator Herminia Dela Cruz and discussed the purpose of today's visit. This two story home is located in a residential neighborhood and has five (5) bedrooms of which four (4) are used as clients bedrooms and the 5th room is the Administrator’s office/lounge, three (3) full bathrooms, a living room, family room, kitchen, dining area, office, backyard, and detached garage. The facility cares for intellectually disabled adults and is vendorized by Frank D. Lanterman Regional Center. Currently, there are four (4) ambulatory clients residing at the home. The Administrator's standard certificate is expiring 10/21/2022. Administrator stated that she has completed the required continuing education courses and mailed the completed certification on 9/16/2022. Annual fee is current and facility has submitted the Infection Control Plan to CCLD.

At 9:18am, LPA and the Administrator toured the facility. The following was observed/inspected:

§ COVID-19 signage was placed in several areas of the facility including the front entrance.
§ Facility maintained a 30-day supply of PPE to include masks, gowns, and face shields.
§ PPE supplies are stored in the storage room inside the home, and some are in the detached garage.
§ Staff wore face masks consistently throughout the shift.
§ All client bedrooms were toured. Each room contained required furniture including bed, dresser, night stand, lamp, chair, and closet. All beds contained the required linens including mattress cover, fitted sheet, flat sheet, blanket, and comforter.
§ Bathrooms are clean and operational and were observed to be within Title 22 regulations. Toilets and water faucets worked properly. Shower was free of mold/mildew and adequate lighting. Bathrooms contained supplies including liquid soap, toilet paper, and paper towels.

CONTINUATION ON LIC 809-C.....
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: NELVILLE GUEST HOME
FACILITY NUMBER: 191222631
VISIT DATE: 10/12/2022
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§ At 9:31am, hot water temperature was checked and read 112.5 deg. F in bathroom #1, 111.2 deg. F in bathroom #2, 111.4 deg. F in bathroom #3 and 111.6 deg. F in kitchen sink which are within the required 105.120 degrees.
§ Kitchen was inspected and LPA observed sufficient perishable and non-perishable food.
§ All the appliances are clean and are operating properly. There is a 2nd refrigerator/freezer in the storage/laundry room with additional food supplies.
§ Knives and other sharp items are stored and locked in a kitchen cabinet which are inaccessible to clients.
§ Laundry room is located inside the home and there are cabinets with locks above the appliances where potentially hazardous cleaning supplies and laundry detergents are stored.
§ At 10:15am, LPA observed that exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. A shaded area with chairs is provided for clients in the patio area.
§ LPA observed that the porch patio ceiling is damaged and in need of repair. The ceiling has deteriorated, decaying and the wood material is sagging.
§ Facility temperature inside the home was comfortable and read at 76 deg. F.
§ First aid kit is fully stocked with manual.
§ Smoke detectors and carbon monoxide detectors were in compliance and operational.
§ No firearms are stored at facility and no bodies of water present.
§ All clients medications were reviewed and LPA observed that medications are stored, locked and inaccessible to clients. Medications are documented properly and given as prescribed.
§ Client files were inspected, and emergency contact information and health screenings were up to date for all clients. Staff files were inspected and contained the required health screenings, criminal record clearances, and training records. All Staff and clients are fully vaccinated with booster.
§ Two (2) fire extinguishers were observed to be fully charged and last serviced on January 10, 2022. One (1) is located in the kitchen/dining area and the other one is upstairs, next to one of the client’s bedroom.

Deficiency was cited under California Code of Regulations Title 22 and documented on the attached LIC 809-D. An exit interview was held and a copy of the report was provided to Administrator, Herminia dela Cruz.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022
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Document Has Been Signed on 10/12/2022 12:27 PM - It Cannot Be Edited


Created By: Bennette Pena On 10/12/2022 at 12:07 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: NELVILLE GUEST HOME
FACILITY NUMBER: 191222631

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) 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 is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which the porch/patio ceiling is damaged and in need of repair. The ceiling is decaying, deteriorated and the wood material is sagging which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2022
Plan of Correction
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The Administrator/Licensee will call a contractor to fix the ceiling in the porch/patio area and send photos, receipts to LPA by fax or email on or before the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2022


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