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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191222631
Report Date: 10/19/2023
Date Signed: 10/19/2023 10:19:56 AM

Document Has Been Signed on 10/19/2023 10:19 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
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: 6DATE:
10/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:11 AM
MET WITH:Hermina DelaCruzTIME COMPLETED:
09:45 AM
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) Kimberly Ramirez conducted an unannounced Annual Required Visit on 10/19/2023. LPA Ramirez was met by Administrator Hermina DelaCruz and explained the purpose of the visit. The facility is licensed serve six (6) developmentally disabled clients 18-59 years old.

The facility currently has zero (0) clients under care and supervision. The facility currently has zero (0) staff working at the facility. The facility transferred all of their clients to other homes due to major remodeling. LPA Ramirez observed a yellow city building permit taped to the front of the facility window upon arrival. Due to the facility being remodeled, LPA Ramirez and construction debris in and around the facility, LPA Ramirez concluded annual due to safety concerns. Due to the facility not caring for any clients at this time, or any staff being present during remodel, LPA Ramirez determined there are no deficiencies to address at this time. Licensee notified this department of construction and remodel on 7/11/23.
Exit interview was conducted with Administrator Hermina DelaCruz. A copy of this report was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2023
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 1