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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600401
Report Date: 08/29/2025
Date Signed: 08/29/2025 04:37:02 PM

Document Has Been Signed on 08/29/2025 04:37 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: DATE:
08/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:06 PM
MET WITH:Herminia V. De La Cruz, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA), Mayra Cota conducted an unannounced required annual visit today. LPA, met with Administrator Herminia De La Cruz and discussed the purpose of today's visit. This single-story home is in a residential neighborhood of Pasadena. The facility is licensed to serve (1) non-ambulatory and (4) ambulatory adults ages 18-59. The facility is operating within the scope of its license. Clients in care receive services from the Frank D. Lanterman Regional Center.

The facility is made up of: living room, dining area, kitchen, staff office, (3) client bedrooms, (2) full bathrooms, side shaded patio, front and backyard, and a detached garage with a laundry area. The home also has a basement in which the water heater and furnace are housed in.

During the visit, the following was observed:

  • Facility was observed clean, inside and out; however, LPA observed several boxes stacked high in the dining area, creating a fall hazard and obstructing the passageway to the refrigerator.
  • Exits were observed clear and free of debris and obstructions.
  • Living room and dining areas have sufficient seating and furniture in good repair.
  • Kitchen appliances were observed clean and were operating at the time of visit, however, live and dead roaches were observed in three cabinets in the kitchen and the dining area.
  • Cleaning supplies and toxins were observed locked in a cabinet under kitchen sink and inaccessible to clients, however, knives/sharps were observed accessible to clients. Knives and kitchen shears were observed unlocked in a kitchen drawer during time of visit. Kitchen drawer latch does not lock due to being the incorrect size to reach the latch. ***Continues on LIC 809-C***
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2025
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 7
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 08/29/2025 04:37 PM - It Cannot Be Edited


Created By: Mayra Cota On 08/29/2025 at 03:37 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 - TOPEKA
FACILITY NUMBER: 198600401

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(c)
Building and Grounds
(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, the licensee did not comply with the section cited above in that several boxes stacked high in the dining area are creating a fall hazard and obstructing the passageway to the refrigerator. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2025
Plan of Correction
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Licensee removed all hazards and obstructions during time of visit.
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 that knives and kitchen shears were observed unlocked in a kitchen drawer and accessible to clients. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2025
Plan of Correction
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Licensee will replace the malfunctioning lock and latch with a new one and ensure they lock properly. Licensee will send LPA a copy of lock purchase receipt and a photo of the replacement installed on to the kitchen drawer by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2025


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 08/29/2025 04:37 PM - It Cannot Be Edited


Created By: Mayra Cota On 08/29/2025 at 03:37 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 - TOPEKA
FACILITY NUMBER: 198600401

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)(1)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.

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 due to live and dead roaches observed in three cabinets in the kitchen and the dining area which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/03/2025
Plan of Correction
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Licensee will submit proof of pest control company service order with an agreement of pest control services of a minimum of 4 weeks.
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, 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 due to window screen in bathroom #2 was observed torn and a window was observed cracked in the staff office which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2025
Plan of Correction
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Licensee will replace torn window screen in bathroom #2 and replace cracked window in staff office by POC due date. Licensee will send LPA a photo of the corrections by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 08/29/2025 04:37 PM - It Cannot Be Edited


Created By: Mayra Cota On 08/29/2025 at 03:37 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 - TOPEKA
FACILITY NUMBER: 198600401

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 due to bathroom #2 delivering water at 89 degree F which is not within the 105-120 degree F range, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2025
Plan of Correction
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Licensee will adjust water temperature and send LPA a log of water temperature being measured in the morning and the evenings (twice a day) along with a photo for each temperature check (thermometer reading).
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

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 due to toillet water tank lid being cracked which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2025
Plan of Correction
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Licensee will replace toilet water tank lid in bahtroom #2 and send LPA a purchase receipt and photo of the replaced item.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
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: 08/29/2025
NARRATIVE
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·Sufficient supply of (2) day perishable and (7) day non-perishable food was observed.
· Overflow refrigerator and freezer are kept in the garage and both contained additional food
· Client bedrooms have the required furniture such as bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. Client beds have the required linen and mattress pads.
· Two (2) full bathrooms were inspected and were observed clean. The water temperature was tested in both bathrooms and measured 105 degrees F in bathroom 1 and 89 degrees F in bathroom 2 which is not within the required 105 - 120 degrees F.
  • Toilet tank cover in bathroom #2 has a crack.
  • Window screen in bathroom #2 was observed torn and a window was observed cracked in the staff office.
  • Client medication was observed on desk in the staff office and accessible to clients.
· Laundry area in the garage is clean and appliances were observed to be working and in good repair.
· Interconnected smoke detectors were observed throughout the facility and were tested and observed to be working properly. The home is also equipped with (1) carbon monoxide detector which was also tested and working properly. There is (1) fire extinguisher located in the kitchen which was observed to be charged and last serviced on 3/29/25.

Outdoor environment:
  • The front and backyard are well maintained and there are no pools or large bodies of water. The side patio furniture was observed and is in good repair. A shaded area is available and garden is kept trimmed.


Due to time constraints, LPA will have to conduct a continuation annual visit at a later time. 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.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025
LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 08/29/2025 04:37 PM - It Cannot Be Edited


Created By: Mayra Cota On 08/29/2025 at 04:04 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: 08/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)

80075(k)(1) Health Related Services (k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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 client medication was observed unlocked in staff office and accessible to clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2025
Plan of Correction
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Licensee corrected the deficiency at the time of visit by removing the medication and locking it in medication cabinet.
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.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2025


LIC809 (FAS) - (06/04)
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