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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191222631
Report Date: 06/14/2022
Date Signed: 06/14/2022 12:26:41 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/09/2022 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220609100709
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: 5DATE:
06/14/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Hermania De La CruzTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Client hit another client while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPAs) Christine Wong and Benette Pena conducted an initial complaint visit and address the abvoe allegation. LPAs met with administrator Hermania De La Cruz and explained the reason of the visit.

The investigation consisted of the following: LPAs Interviewed the administrator, two staff (S1-S2), two clients (C4-C5) and attempted to interview three clients (C1-C3). LPAs also reviewed C1's documents include C1's face sheet, Pre-appraisal, Needs and Service Plan and Individual Program Plan (IPP).

The investigation revealed of the following: Allegation "Client hit another client while in care." LPA interviewed staff and reported C1 just moved to the above facility for three months and C1 is still adjusting at the above home. C1 used to live with the family and he can get whatever he wants. The incident was happened during lunch time, C1 was obsessed with food but limited and selective food choices, while the staff was preparing C1's lunch (See LIC9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 28-AS-20220609100709
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: NELVILLE GUEST HOME
FACILITY NUMBER: 191222631
VISIT DATE: 06/14/2022
NARRATIVE
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He grabbed other client food and throw it away. Then C1 went to C2 who was sitting on the sofa and hit his shoulder twice with unknown reason. Staff immediately went and talked to C1 and asked him to calm down and redirect him and then C1 hit himself on his head too. Administrator reported there's no injury for C2 and does not need any medical attention. Administrator reported that C1 has had aggressive behavior in the past and this is the first time C1 was hitting someone in the home. After the incident, the administrator called off a meeting with all of C1's responsible party and decided to prescribe C1 with a mood stabilizer medication and expertise the process for C1's day program. Therefore there was insufficient evidence to corroborate with this allegation.

Based on LPA observations, interviews conducted, and a review of documents obtained; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur; therefore the allegation is UNSUBSTANTIATED.

Exit Interview Conducted and copy of this report and appeal right was provided to administrator Hermania De La Cruz.
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2