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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191222631
Report Date: 06/14/2022
Date Signed: 06/14/2022 12:29:36 PM

Document Has Been Signed on 06/14/2022 12:29 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
CCLD Regional Office, 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: 5DATE:
06/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator-Hermania De La Cruz TIME COMPLETED:
12:15 PM
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
During the complaint investigation, Licensing Program Analysts (LPAs) Christine Wong and Benette Pena interviewed administrator and reported that they did not report the incident about client#1 hit client#2 to any responsible party on April, 2022. Administrator reported due to there's no medical attention needed and its not reportable. Therefore she did not file any incident report and assigned LPA got any incident report from administrator too.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation.

An exit interview was conducted and a copy of the report and Appeal Rights were provided to Administrator Hermania De La Cruz
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR 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.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 06/14/2022 12:29 PM - It Cannot Be Edited


Created By: Christine Wong On 06/14/2022 at 12:12 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: 06/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/21/2022
Section Cited
CCR
80061(b)(1)(E)

1
2
3
4
5
6
7
80061 Reporting Requirements (b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) ........ next working day during its normal business hours.(1) Events reported shall include the following:
1
2
3
4
5
6
7
The administrator will ensure the reporting requirement needs to be met and the administator will read the regulation and retrain the staff about the reporting requirement and send the training log to LPA by POC due date.
8
9
10
11
12
13
14
(E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.The requirement is not met as evidenced by: Administrator did not report the incident for C1 hit C2.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Christine Yee
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2