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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191222631
Report Date: 10/16/2025
Date Signed: 10/16/2025 11:28:27 AM

Document Has Been Signed on 10/16/2025 11:28 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/
DIRECTOR:		HERMINIA DELACRUZFACILITY TYPE:
735
ADDRESS:2005 E. ORANGE GROVE BLVD.TELEPHONE:
(626) 791-1170
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 0DATE:
10/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Zosimo Pascasio - StaffTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced required 1-year visit. LPA rang the doorbell upon arrival to gain entry but no one answered the door. LPA proceeded to call the Licensee, Glorie Pascasio and explained the purpose of the visit. Several minutes later, Staff Zosimo Pascasio arrived and assisted LPA with the inspection. The facility is licensed to serve six (6) developmentally disabled clients 18-59 years old and is vendorized by San Gabriel/Pomona Regional Center. Facility is current on licensing fees. LPA observed that the home is still undergoing minor changes inside but has completed most of the major renovations. Licensee notified CCLD of the construction and remodel on 07/11/2023. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today.
There are zero (0) clients under care and supervision and zero (0) staff working at the facility. LPA and staff toured the facility inside and out. The facility is a 2 story home located in a residential neighborhood and consists of (6) bedrooms: (4) client bedrooms downstairs, (2) bedrooms upstairs, (2) bathrooms, living room, family room, kitchen, dining area, office, gated backyard and detached garage. Licensee, Glorie Pascasio stated that the application for Change of Ownership will be submitted by end of October 2025 and only the first floor will be licensed. All client bedrooms were toured. Bedrooms have the required bed, bedframe, dresser, light, and closet space. Bathrooms are clean and operational and were observed to be within Title 22 regulations. There were no toxic chemicals accessible to clients. The kitchen was inspected and observed new appliances which have not been installed. There is another refrigerator/freezer in the pantry area next to the laundry machines. Sufficient space to accommodate both indoor and outdoor activities was observed. No firearms are stored at facility and no bodies of water present. There are no medications reviewed today. LPA observed a fire extinguisher that is fully charged. Exit walkways and/or passageways, front and back yard are free of debris and/or hazards. No client and staff files reviewed during the visit.
LPA concluded the required 1-yr visit. The facility is not providing care for any clients at this time, nor staff present during the renovation.

Per California Code of Regulations, Title 22, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided to Zosimo Pascasio, Staff.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2025
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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