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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600401
Report Date: 09/26/2023
Date Signed: 09/26/2023 02:26:53 PM


Document Has Been Signed on 09/26/2023 02:26 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 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: 4DATE:
09/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Herminia Dela CruzTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 09/26/2023. LPA Ramirez was met by Administrator Dela Cruz and explained the purpose of the visit. The facility is licensed serve six (6) developmentally disabled clients 18-59 years old. LPA Ramirez requested and obtained copies of Personnel Report (LIC 500), and Client Roster (LIC 9020). All clients in the home receive services from Frank D. Lanterman Regional Center.

LPA OBSERVATIONS: Tour began at 11:35 am and was led by Administrator Dela Cruz. The facility is a single-story building located in a residential area with four (4) client bedrooms, one (1) staff office, three (3) bathrooms, kitchen, dining room, living room, detached garage, front yard, backyard.

Front Yard: LPA Ramirez observed roofers on the roof of facility upon arrival. LPA Ramirez observed several planks plywood with nails attached in a pile. LPA Ramirez observed a ladder reaching to the roof area blocking facility door entrance. LPA Ramirez will issue two (2) Technical Violations based on observations. Facility will instruct clients, staff and visitors to use facility side entrance until debris has been removed. Although facility roof is in disrepair, facility was aware and made attempts to repair roof but local code enforcement was delaying final approval of permit.

Kitchen: LPA Ramirez observed appliances to be in working order. LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located in kitchen cabinet, to be inaccessible to four (4) out of four (4) clients in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in bottom kitchen cabinet to be inaccessible to four (4) out of four (4) clients in care. LPA Ramirez observed a fully charger fire extinguisher nearby. Kitchen sink water temperature was measured at 109.1 degrees F.

Dining Room/Living room: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed with plenty of lighting. LPA Ramirez observed a fully charged fire extinguisher nearby. LPA Ramirez observed signage promoting cough and handwashing etiquette in this area. LPA Ramirez observed nearby thermostat to read 71 degrees F.

Linen Closet/Supply Closet: Contained plenty linens, towels, and hygiene products.

SEE 809-C for continuation.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 - TOPEKA
FACILITY NUMBER: 198600401
VISIT DATE: 09/26/2023
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Client Rooms 1 - 4: LPA Ramirez observed all client bedrooms to contain the required linens, furnishings, and lighting. LPA Ramirez observed all rooms to be clean.

Bathroom 1-2: Water temperature in client bathroom#1 was measured at 108.8 degrees F which is in the required 105 – 120 degrees F. LPA Ramirez observed signage promoting proper handwashing etiquette near sink. Client bathroom #2 water temperature was measured at 107.7 degrees F. Client bathroom #2 is a half bathroom. LPA Ramirez observed grab bars in all showers and non slip mats in bathroom shower.

Centrally Stored Medications: LPA Ramirez observed medications to be locked in staff office. LPA Ramirez reviewed four (4) client medications administration records (MAR).

Backyard: No large bodies of water were observed.

Emergency Drills (Conducted every 6 months): Proof of last documented earthquake drill was on 5/9/23 at 3:30 pm and last documented fire drill was conducted on 5/17/23 at 4:00 pm.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide and smoke detectors in hallways. Smoke detectors were observed to be operable during visit.

Staff Personnel Files: Staff files are maintained at the facility. LPA Ramirez reviewed three (3) staff files. LPA Ramirez observed a current Administrator’s certificate for Herminia Dela Cruz with an expiration date of 10/21/24.

Client Files: Four (4) client files were reviewed.

Infection Control Plan: LPA Ramirez reviewed current approve Infection Control Plan.

Exit interview was conducted with Administrator Dela Cruz. Two (2) Technical Violations were given. A copy of this report, LIC 9102, and appeals rights was provided.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023
LIC809 (FAS) - (06/04)
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