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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600166
Report Date: 06/27/2023
Date Signed: 06/27/2023 12:45:28 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
06/22/2023 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230622155532
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:
06/27/2023
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Zonel Pascasio (Tony) TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff mismanaged clients' medications.
Facility failed to meet reporting requirements in a timely manner.
Facility failed to comply with the requirements for back up Administrator.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Wong conducted an intial 10 days complaint and addressed the above allegation(s). LPA met with DSP Teresita Del La Cruz and explained the reason of the visit. Shortly after, the back up administrator Zonel Pascasio arrived and assisted with the visit.

The investigation consisted of the following: On today's date, LPA interviewed the back up administrator, two staff (S1-S2), one client (C1) and attempted to interview three clients (C2-C4) and reviewed Cl-C4 medication and Medication Administraton Records (MARs) and obtained a copy of back up administrator notice letter to CCL dated on 6/26/23 and copy of two incident reports dated on 4/11/23 and 6/8/23.

The investigation revealed of the following: Allegation#1 "Staff mismanged clients' medications" LPA reviewed all four clients medication in the facility and observed C2's PRN medication Lorazepam 0,5mg was not indicated on the MARs.
(See LIC9099C for continuation)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023
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 4
Control Number 28-AS-20230622155532
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 198600166
VISIT DATE: 06/27/2023
NARRATIVE
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LPA observed the staff had been documented the date and time that C2 took the medicine on the back of MARs. It documented 10 times on the MARs but on the bubble pack medication, 11 days of medication was taken out (dated June 1st to 11th) and LPA asked staff and they were not able to explain the reason.

Allegation#2 "Facility failed to meet reporting requirements in a timely manner." LPA reviewed the CCL internal incident reports and unusual incident reports that submitted by the facility and LPA did not observe the facility sent any incident report on 4/11/2023 about C3's AM medication was not dispensed and staff initiated on the MARs.

Allegation#3 "Facility failed to comply with the requirements for back up Administrator." LPA spoke to the staff and the back up administrator and reported the administrator on file had been out from the facility for couple weeks and they admitted they never reported to CCL for the changes of the facility and who is responsible to carry out the administrator responsibilities during administrator absence and never sent any supported documents to CCL until June 26th, 2023 via mail. LPA also never received any LIC308 (Destination of Facility Responsibility) prior today's visit.

Based on the record reviewed, and interviewed conducted with staff, the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

Exit Interview conducted and copy of the report and appeal right were provided to the back up administrator Zonel Pascasio
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20230622155532
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 198600166
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
06/28/2023
Section Cited
CCR
80075(b)(5)(C)
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80075 Health Related Services (b)Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5)If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication.....all of
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Back up Administrator will schedule an in-service training on Medication Management for all facility staff in charge of medication administration and date provided to Licensing by POC due date. A copy of the materials discussed during the training and signatures of all staff present must be forwarded to
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the following requirments are met (C) A record of each dose is maintained in the client's record. The requirement was not met as evidenced by record review, LPA observed C2's MARs documentation and the bubble pack medication were not matched
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 the CCL office upon completion.

(POC cleared during the complaint visit
Staff had the in service training about medication manangement on 6/9/23)
Deficiency Dismissed
Type B
07/11/2023
Section Cited
CCR
80061(b)(1)(E)
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80061 Reporting Requirements
(b) (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.
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The back up administrator shall review Section 80061 (Reporting Requirements) and ensure that all reporting requirements will be met for future incidents and provide a signed statement to the department indicating the licensee understands the requirements by the POC date.
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(1) Events reported shall include the following:
(E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. The requirement was not met as evidenced by record review, LPA reviewed CCL internal incident reports and unsusal reports and facility did not send the incidnet report about missing medication for C2 on 4/11/23
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(POC cleared during the complaint visit. Staff had in service training for SIR reporting on 6/23/23)
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: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20230622155532
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 198600166
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
07/11/2023
Section Cited
CCR
80064(b)
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80064 Administrator-Duties and Qualifications (b) Each licensee shall make provision for continuing operation and carrying out of the administrator's responsibilities during any absence of the administrator.
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The administrator will provide an updated LIC 308 and the back up administrator documents infomration to CCL by POC due date.

(POC cleared during the complaint visit about change of administrator documentts )
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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: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4