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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600401
Report Date: 09/12/2022
Date Signed: 09/12/2022 02:28:13 PM

Document Has Been Signed on 09/12/2022 02:28 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 HOME - TOPEKAFACILITY NUMBER:
198600401
ADMINISTRATOR:DELA CRUZ, HERMINIAFACILITY TYPE:
735
ADDRESS:1570 EAST TOPEKA STREETTELEPHONE:
(626) 798-1685
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 5CENSUS: 3DATE:
09/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Herminia dela Cruz, AdministratorTIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Annual Required / Infection Control visit to the above facility. Upon arriving at the facility, LPA knocked on the door but there was no answer. LPA called the facility and left a voicemail message, to advise that LPA was outside the door. At 9:51am, LPA called the Administrator, Herminia dela Cruz at cell: 626-354-9972 and advised of the situation. Administrator stated she will call her staff in the house to let me in, and that she will come over to the facility. At 9:57am, LPA was met by Imelda Chan, DSP II and House Manager. Administrator arrived at 10:26am and the purpose of today’s visit was explained. There are currently 3 clients in the facility. All current clients are serviced by Frank D. Lanterman Regional Center. The facility is licensed to serve five (5) developmentally disabled clients (age 18-59) and is approved for one (1) non-ambulatory client. Annual fees are current.

LPA and Administrator inspected the entire facility inside and out. The facility is a conventional single-story home located in a residential neighborhood. Home consists of 3 bedrooms, 2 bathrooms, Office, dining area, living room, kitchen, laundry located in a detached garage, and outside area backyard porch with outdoor activity area and shaded seating area for clients. COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility, and in all common rooms’, bathrooms, and hallways. DSP II did not screen LPA upon arrival. She did not know the Covid-19 protocol for screening all visitors. And she did not know how to use the digital thermometer and did not know where the visitors sign in sheet was located. DSP II was observed to wear a mask. Facility has an adequate amount of PPE and facility has enough PPE for 30 days.


CONTINUED ON LIC 809C...
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 - TOPEKA
FACILITY NUMBER: 198600401
VISIT DATE: 09/12/2022
NARRATIVE
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At 10:35am, LPA and Administrator toured the kitchen. Freezers/refrigerators appear sanitary and temperature maintained. There was sufficient supply of perishable for 2 days & non-perishable foods for 7 days. The hot water was tested and read at 113.9 deg F which is within the Title 22 regulations. There was one (1) fire extinguisher located next to the refrigerator and appeared to be fully charged. It was last serviced and inspected on 08/08/2022. LPA also observed that knives, other sharp items, hazardous toxins and/or items are locked in their respective cabinets in the kitchen area and inaccessible to clients.

All three (3) clients’ rooms were checked. Client bedroom # 1 did not have window blinds, but only had a temporary red colored curtain which was not enough to cover the entire window. Administrator replaced the curtain which gave proper privacy to the client. LPA observed that client #2 bedroom which was unoccupied had a broken window. The window glass pane had shards, the size of the crack was approximately 15" x 15" and have sharp edges. The beds in all 3 clients bedrooms have the required linens which were in good condition at the time of the visit. LPA observed that all bedrooms were well-lit and had sufficient closet/ storage space.

Bathrooms were clean and operational and were observed to be within Title 22 regulations. Toilets and water faucets worked properly. Shower was free of mold/mildew, adequate lighting, and sufficient toiletries were accessible to clients. Water temperature properly measured at 113.9 deg F in Staff bathroom (bathroom #1). Clients bathroom’s (Bathroom #2) hot water temperature read at 116.6 deg F.

LPA observed that smoke detectors and carbon monoxide detectors were operational. No firearms were stored at the facility and no bodies of water present. Medications were stored, locked in the office and inaccessible to clients.

CONTINUED ON LIC809C...

SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 - TOPEKA
FACILITY NUMBER: 198600401
VISIT DATE: 09/12/2022
NARRATIVE
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At 10:50am, LPA toured the backyard along with the Administrator and observed debris, broken wood materials and yard waste accumulated in the side and backyard areas. LPA observed a shaded area with chairs provided for clients and visitors in the patio area which was located right outside the kitchen area. The facility was in good repair and comfortable temperature inside the home that read 75 deg F for clients was maintained. LPA inspected physical plant, food supply, clients & staff record review and medication. First aid kit was inspected and observed to be fully stocked with manual and in compliance with Title 22 Regulations LPA observed the facility to be clean and appropriately furnished with clear passageways inside.

The Facility Administrator Certificate for Herminia De La Cruz expires on 10/21/2022. The fire drill for staff and clients was conducted on 02/16/2022 and earthquake drill was conducted on 02/15/2022. Upon inspection of the staff records, LPA found out that DSP II Imelda Chan was not associated in the facility as of yet. Administrator stated that DSP II started work last Thu., 9/08/2022, with a 9am-5pm schedule. LPA observed that DSP II’s criminal background clearance was cleared, however, Administrator still have to associate her in the facility. Administrator will send DSP II home and will not allow to go back to work until cleared. Administrator stated that DSP II had worked in the facility 4 years ago. LPA told the Administrator to use Guardian to associate DSP II.
Administrator was also reminded to submit the Infection Control Plan for the facility. The deadline for submission was June 30, 2022.

Deficiencies were observed and cited per California Code of Regulations, Title 22, Division 6. Exit interview was conducted, a copy of this report and Appeal Rights were provided to Herminia De La Cruz, Administrator.

NOTE: System glitch; LPA could not locate the previous report and the inspection tool report that were already completed. LPA had to re-do everything from scratch.

SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 09/12/2022 02:28 PM - It Cannot Be Edited


Created By: Bennette Pena On 09/12/2022 at 01:52 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 - TOPEKA
FACILITY NUMBER: 198600401

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the licensee did not comply with the section cited above in which debris, yard waste and broken wood materials were accumulated in the backyard and side areas of the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2022
Plan of Correction
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The Administrator will send photos to LPA/CCLD showing that the backyard and side areas have been cleaned of debris, broken wood materials and yard wastes on or before the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Christine Yee
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2022


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Document Has Been Signed on 09/12/2022 02:28 PM - It Cannot Be Edited


Created By: Bennette Pena On 09/12/2022 at 01:57 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 - TOPEKA
FACILITY NUMBER: 198600401

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in which one staff (DSP II) was not associated to the facility when she started work on 9/8/2022 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/05/2022
Plan of Correction
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Administrator will call or email LPA Pena to advise the clearance and association of one of their staff, DSP II Imelda Chan on or before the POC due date. At the time of visit, Administrator sent DSP II home and will not be allowed to work until cleared to work.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Christine Yee
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2022


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 09/12/2022 02:28 PM - It Cannot Be Edited


Created By: Bennette Pena On 09/12/2022 at 02:02 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 - TOPEKA
FACILITY NUMBER: 198600401

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b0
80088
Furniture, Fixtures, Equipment, and Supplies

(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which the window glass pane in unoccupied client's bedroom was broken which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2022
Plan of Correction
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The Administrator will send photo(s) of the the fixed or new window glass pane in client's bedroom to LPA/CCLD on or before the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Christine Yee
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2022


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