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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600166
Report Date: 06/16/2021
Date Signed: 06/16/2021 05:29:36 PM

Document Has Been Signed on 06/16/2021 05:29 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:
198600166
ADMINISTRATOR:NELIA V. PASCASIOFACILITY TYPE:
735
ADDRESS:9432 RALPH STREETTELEPHONE:
(626) 443-4192
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY: 5CENSUS: 2DATE:
06/16/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Nelia Pascasio, AdministratorTIME COMPLETED:
05:35 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
Licensing Program Analyst (LPA) Galarza conducted a Case Management-Deficiencies visit due to observations made during complaint control #: 28-AS-20210610112238 visit. LPA met with Administrator Nelia Pascasio and explained the purpose of the visit. Eastern Los Angeles Regional Center Community Services Specialist Maria Cano was present during the visit.


The following were observed/inspected:
  • At 2:18 pm the front door was observed to have two chain door guard locks in the upper portion of the door. The dining room exit door had one chain door guard lock. Administrator stated they were installed years ago to prevent a former client from AWOL.

  • At 2:23 pm cockroaches were observed in the lower kitchen cabinets. Video and pictures were taken. Staff (S2) confirm pest issues in the home.


Deficiencies are cited in LIC 809D.

Exit interview conducted with Administrator Nelia Pascasio. Appeal Rights were issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
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.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 06/16/2021 05:29 PM - It Cannot Be Edited


Created By: Noemi Galarza On 06/16/2021 at 04:37 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: 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
80072(a)(7)

1
2
3
4
5
6
7
80072(a)(7)Personal Rights. Each client has the right not to be locked in any room, building, or facility premises by day or night.

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administrator shall remove the chain door guard locks in the main entrance door and dining room exit door.

Submit self-certification and pictures of main entrance door and dining exit door by tomorrow. If LPA returns to the facility and observes the locks civil penalties will be assessed.
8
9
10
11
12
13
14
Based on observation at 2:18 pm the front door was observed to have two chain door guard locks in the upper portion of the door. The dining room exit door had one chain door guard lock. This poses and immediate health and safety risk to clients in care.
8
9
10
11
12
13
14
Type B
07/21/2021
Section Cited
CCR80072(a)(2)

1
2
3
4
5
6
7
80072(a)(2) Personal Rights. Each client has the right to be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

***This requirement has not been met by evidence of:
1
2
3
4
5
6
7
Administrator shall ensure that staff clean regularly and report any pest control issues. Conduct staff training and submit training log, and a copy of the pest control service invoice.
8
9
10
11
12
13
14
Based on observation at 2:23 PM cockroaches were observed in the lower kitchen cabinets. DSP staff confirmed cockroaches have been seen in the home. 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
LICENSING EVALUATOR NAME:Noemi Galarza
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


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