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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600401
Report Date: 08/13/2024
Date Signed: 08/13/2024 01:50:52 PM

Document Has Been Signed on 08/13/2024 01:50 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:NELVILLE GUEST HOME - TOPEKAFACILITY NUMBER:
198600401
ADMINISTRATOR/
DIRECTOR:		DELA CRUZ, HERMINIAFACILITY TYPE:
735
ADDRESS:1570 EAST TOPEKA STREETTELEPHONE:
(626) 798-1685
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 5CENSUS: 4DATE:
08/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:01 AM
MET WITH:Administrator, Herminia dela CruzTIME VISIT/
INSPECTION COMPLETED:
01:49 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) Sanjay Vaid conducted an unannounced required-1 year inspection focusing on the CARE tools. LPA Vaid met with Administrator Herminia Dela Cruz and discussed the purpose of today's visit. This single story home is located in a residential neighborhood and has five (5) bedrooms of which four (4) are used as clients bedrooms and the 5th room is the Administrator’s office/lounge, two (2) full bathrooms, a living room, family room, kitchen, dining area, office, backyard, and detached garage, the basement houses the water heater and furnace. The facility cares for intellectually disabled adults and is vendorized by Frank D. Lanterman Regional Center. Currently, there are four (4) ambulatory clients residing at the home. All clients are at day program and could not be interviewed. The Administrator's standard certificate is expiring 10/21/2024. Annual fee is due $454.00, pin number was provided the facility will make the payment today. Infection Control Plan has been submitted to CCLD.

LPA and the Administrator toured the facility. The following was observed/inspected:

All client bedrooms were toured. Each room contained required furniture including bed, dresser, night stand, lamp, chair, and closet. All beds contained the required linens including mattress cover, fitted sheet, flat sheet, blanket, and comforter.
Bathrooms are clean and operational and were observed to be within regulations. Toilets and water faucets worked properly. Shower was free of mold/mildew and adequate lighting. Bathrooms contained supplies including liquid soap, toilet paper, and paper towels.
Hot water temperature was checked and read 106.9 deg. F in bathroom #1, 107.5 deg. F, bathroom #2, and 111.6 deg. F, and the kitchen sink which are within the required 109.4 degrees.
Kitchen was inspected and LPA observed sufficient perishable and non-perishable food.
All the appliances are clean and are operating properly. There is a 2nd refrigerator/freezer in the storage/laundry room with additional food supplies.
Knives and other sharp items are stored and locked in a kitchen cabinet which are inaccessible to clients.
Continued on 809 C...
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2024
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: NELVILLE GUEST HOME - TOPEKA
FACILITY NUMBER: 198600401
VISIT DATE: 08/13/2024
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
26
27
28
29
30
31
32
LPA observed that exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. A shaded area with chairs is provided for clients in the patio area.
First aid kit is fully stocked with manual. Smoke detectors and carbon monoxide detectors were in compliance and operational. No firearms are stored at facility and no bodies of water present. All clients medications were reviewed and LPA observed that medications are stored, locked and inaccessible to clients. Medications are documented properly and given as prescribed.
Client files were inspected, and emergency contact information and health screenings were up to date for all clients. Staff files were inspected and contained the required health screenings, criminal record clearances, and training records. All Staff and clients are fully vaccinated with booster.
Two (2) fire extinguishers were observed to be fully charged and last serviced January 17, 2024. One (1) is located in the kitchen/dining area and the other one is next to one of the client’s bedroom.

No deficiencies were observed on today's visit. An exit interview was held and a copy of the report was provided to Administrator, Herminia dela Cruz.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2