198600166-6-16-2021-28-AS-LHIS-C6VTAW-20210915143414

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600166
Report Date: 06/16/2021
Date Signed: 06/16/2021 05:30:06 PM

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
06/10/2021 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210610112238

FACILITY NAME:	NELVILLE GUEST HOME		FACILITY NUMBER:	198600166
ADMINISTRATOR:	NELIA V. PASCASIO		FACILITY TYPE:	735
ADDRESS:	9432 RALPH STREET		TELEPHONE:	(626) 443-4192
CITY:	ROSEMEAD	STATE: CA	ZIP CODE:	91770
CAPACITY:	5	CENSUS: 2	DATE:	06/16/2021
		UNANNOUNCED	TIME BEGAN:	02:05 PM
MET WITH:	Nelia Pascasio, Administrator		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Cleaning supplies were accessible to residents.
The facility failed to keep the facility safe and in good repair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted an initial complaint visit to investigate the above allegation. The purpose of the visit was discussed with DSP staff Teodorico Santa Maria. Administrator Nelia Pascasio arrived later.

The investigation consisted of the following: At approximately 2:15 pm LPA toured the facility interior and exterior grounds. Eastern Los Angeles Regional Center Community Services Specialist Maria Cano was present during the visit. LPA observed health and safety issues during the time of this visit. The garage was full of items that were blocking access into the garage. In addition, disinfectant solutions, laundry detergents, and sharps were observed to be unlocked. The knife/sharps drawer in the kitchen was unlocked at the time of the visit. Staff (S2) immeditely locked the drawer. Repairs to the kitchen stove, outdoor wooden fence, floor tiles were observed to be needed.

See LIC 9099C for report continuation.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210610112238

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: 198600166
	VISIT DATE: 06/16/2021

NARRATIVE

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Allegation: "Cleaning supplies were accessible to residents." On 6/9/2021, reporting party observed the cabinet below the kitchen sink to be unlocked. It contained cleaning supplies accessible to clients in care. Staff reported the lock was broken. Staff interviews revealed the lock had been broken for at least one (1) week. During today's visit, cleaning supplies were observed to be unlocked in the garage that is accessible to one (1) client in care that occasionally does its own laundry.

Allegation: "The facility failed to keep the facility safe and in good repair." Based on observation the findings indicate the facility is in disrepair. The outdoor wooden fence in the back and side yard is broken with nails sticking out. Administrator stated the fence will be repaired soon. New wooden materials were observed in the side yard floor. In addition, the garage was filled with boxes, old furniture, and storage materials. Access to the garage was limited because there was no passage way as a result of the quantity of items in the garage. This poses an immediate health and safety hazard. At 2:23 pm the kitchen stove was observed to have four non-operable stove burners. Staff (S2) stated a lighter is used to turn the stove on. Only one (1) stove burner works without using the lighter to ignite the burner. The electrical outlet in the dining room was missing a cover and one (1) floor tile in the dining room is loose with sharp edges.

Deficiencies are being cited based on LPA observation and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC 9099D.

An exit interview was conducted and Plans of Correction were reviewed and developed with Administrator. A copy of the report and appeal rights were discussed and left with Administrator Nelia Pascasio.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210610112238

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: 198600166
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/17/2021 Section Cited CCR 80087(g)	1 2 3 4 5 6 7	80087(g). Buildings and Grounds. Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met by evidence of:	1 2 3 4 5 6 7	Administrator agreed to conduct training to all staff, and regularly check that staff are following facility protocols. Submit a written plan, staff training sign in sheet, and picture proof of corrections by POC due date.
	8 9 10 11 12 13 14	Based on interviews conducted, on 6/9/21 the cabinet below the kitchen sink was observed to be unlocked. It contained disinfecting solutions. In addition, during today's visit, disinfectant solutions were observed unlocked in the garage. and the kitchen drawer containing sharps was unlocked. This poses and immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 07/21/2021 Section Cited CCR 80087(a)	1 2 3 4 5 6 7	80087(a). The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met by evidence of:	1 2 3 4 5 6 7	Administrator agreed clear the garage of excess storage, repair or replace the backyard wooden fence, repair/replace the kitchen stove, and the loose floor tile. Submit picture proof of corrections by POC due date.
	8 9 10 11 12 13 14	Based on physical plant inspection LPA observed the garage was filled with boxes, discarded furniture, and storage items. In addition, the backyard wooden fence, kitchen stove, floor tiles, and dining room electrical outlet were observed to be in need of repairs. This poses a potential health and safety risk to clients in care.	8 9 10 11 12 13 14

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

LIC9099 (FAS) - (06/04)

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