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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600166
Report Date: 02/09/2023
Date Signed: 02/09/2023 04:29:35 PM

Document Has Been Signed on 02/09/2023 04:29 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
GREATER LA AC/SC, 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:
02/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Rhea SantaMaria, StaffTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the unannounced annual inspection with the focus primarily on the Infection Control domain. LPA met with Staff, Rhea SantaMaria, and explained the purpose of the visit. The facility is licensed to serve 5 ambulatory developmentally disabled adults ages 18 through 59. There are currently 4 ambulatory adults residing at the home and receive services by the Eastern Los Angeles Regional Center.

LPA toured the facility inside and out and the following were inspected:
* There is one main entry point for staff and visitors. Upon arrival, the staff took LPA's temperature and documented on log. The facility has a poster for symptom checks by the entryway.
* There are 3 bedrooms, 2 bathrooms, living room, family room, dining area, kitchen, attached garage, and a office room in the backyard. The bedrooms are clean and have the required furnishing. The bathrooms have the recommended hand washing sign. Covid-19 signage are posted throughout the home.
* Staff are cleaning and disinfecting at least every 2 hours.
* Food supplies are sufficient.
* Emergency contact information are posted where easily accessible.
* Extra PPE supplies are stored at the house.
* Staff were wearing face masks.
* The smoke detectors and a carbon monoxide were tested and operable.
* Medications were checked for all 4 clients. No discrepancies found.
* The facility has an approved mitigation plan in which they are still following. They are able to obtain more staffing if needed.
LPA provided technical assistance for the following items: * additional signage needed at the main entrance
* Provider Information Notices (PINs) should be in an accessible location.
There are no deficiencies observed today. An exit interview was held and a copy of this report was provided to the Staff.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2023
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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