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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600166
Report Date: 02/10/2022
Date Signed: 02/10/2022 02:04:57 PM

Document Has Been Signed on 02/10/2022 02:04 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:
198600166
ADMINISTRATOR:NELIA V. PASCASIOFACILITY TYPE:
735
ADDRESS:9432 RALPH STREETTELEPHONE:
(626) 443-4192
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY: 5CENSUS: 4DATE:
02/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:07 PM
MET WITH:Nelia Pascasio, AdministratorTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Administrator Nelia Pascasio and explained the purpose of the visit. There are four (4) level 4i developmentally disabled resident ages 18-59. The facility is serviced by Eastern Los Angeles Regional Center. The facility is a single story home located in a residential neighborhood that is licensed for 5 ambulatory only residents. It consists of 3 bedrooms, living room, family room, dining room, kitchen,2 bathrooms, detached garage with laundry area, outdoor patio, and office in the rear of the facility. The last fire drill was conducted on 8/22/21. Administrator certificate expires 12/25/2022.

The following were observed/inspected:
  • The interior and exterior physical plant was inspected. Staff was observed wearing a surgical mask.
  • COVID-19 Infection Control screening and signs were observed in the entrance area, and bathrooms.
  • Facility has an approved COVID-19 Mitigation Plan.
  • Room # is designated as a COVID-19 solation room if needed.
  • Two (2) centrally stored resident medication record was reviewed.
  • Residents in care do not wear masks because it is not tolerated due to cognitive impairment.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days was observed.
  • Personal Protective Equipment (PPEs) were observed.
  • The Emergency Disaster Plan was posted.
  • Staff and resident files were not reviewed during today's visit.
  • No health and safety issues were observed.


No deficiencies were cited.

Exit interview was conducted with staff Nelia Pascasio. A copy of the report was issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2022
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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