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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191222631
Report Date: 12/19/2023
Date Signed: 12/19/2023 02:55:46 PM

Substantiated


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
03/27/2023 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230327112739
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: 0DATE:
12/19/2023
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Administrator Herminia Delacruz TIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Staff did not seek timely medical care for client in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent complaint investigation visit for the allegation above. LPA met with Administrator Herminia De La Cruz and the purpose of the visit was discussed.

Initial visit on 3/30/2023 consisted of the following: LPA interviewed Staff #1-#2 (S1-S2) and Clients #2-#4 (C2-C4) and toured the physical plant. LPA unable to interview Client #1 (C1) as they are currently not in the facility. LPA collected documents from the facility from C1's file as well as a copy of the staff and resident roster.

On todays visit LPA observed the facility does not have any clients and is under construction. LPA unable to interview C1. LPA delivered findings. The investigation revealed the following:

Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
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 3
Control Number 28-AS-20230327112739
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: 12/19/2023
NARRATIVE
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In regards to the allegation "Staff did not seek timely medical care for client in care" it was alleged that C1 had a fall in the facility and was not provided medical care in a timely manner. (2) of (2) Staff interviewed denied the allegation. (3) of (3) Clients interviewed could not corroborate the allegation. Interviews show that C1 had a fall in the facility on 3/17/23 when they attempted to lift a heavy chair and it fell on C1 chest/shoulder. Interviews stated that C1 was assessed and no medical treatment was provided as it was determined to not be needed after the initial injury. File review shows that C1 had another fall on 3/18/23 while in the bathroom where staff was present and first aid assistance was provided for a cut on the toe. Interviews with staff show that staff noticed the bruising on C1 began to show on the upper back. The bruising spread from their upper back to the front shoulder but C1 was not provided further medical assistance until 3/25/23. Interviews with staff stated that on 3/25/23 C1 was having general weakness and was unable to get up so that is why paramedics were finally called. This shows that the facility failed to seek medical attention in a timely manner for the bruising that spread from back to the front side of C1s shoulder between 3/17/23 up to 3/25/23. Based on interviews, record review and observations the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Per Title 22, deficiencies are cited.

Exit Interview conducted. Appeal rights discussed. A copy of this report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20230327112739
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2023
Section Cited
CCR
80075(a)
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80075 Health Related Services(a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services... This was not met as evidenced by:
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Facility currently has no clients or staff on site. Licensee to review Title 22 80075 and provide LPA documentation signed stating that it has been done by POC due date.
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Facility failed to provide medical assistance to C1 for the large bruising that spread from their shoulder to the back. This poses a potential health and safety risk to clients in care.
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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.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3