198601057-2-8-2022-28-AS-ALOZ-CBFSLH-20220208125821

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601057
Report Date: 02/08/2022
Date Signed: 02/08/2022 12:59:04 PM

Document Has Been Signed on 02/08/2022 12:59 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-WASHINGTON		FACILITY NUMBER:	198601057
ADMINISTRATOR:	PASCASIO, NELIA		FACILITY TYPE:	735
ADDRESS:	1250 EAST WASHINGTON BLVD.		TELEPHONE:	(626) 791-2665
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY: 6		CENSUS: 6	DATE:	02/08/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:58 AM
MET WITH:	Leilani Pacasio, Administrator		TIME COMPLETED:	01:01 PM

NARRATIVE

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On 02/08/2022 Licensing Program Analyst (LPA) Alberto Lopez, conducted a required annual inspection focused on infection control. LPA was greeted by Dolores Murrillo DSP. Administrator Leilani Pascasio arrived a short time later and joined LPA. LPA discussed the purpose of the visit. Currently, the home has (6) ambulatory clients and (0) non-ambulatory client. The facility is housed with Frank Lanterman Regional Center clients with ages of 18-59. As a part of the inspection, LPA inspected the inside/outside facility grounds. The last fire and earthquake drill were conducted on 10/05/2021. Administrator Certificate expires: 03/14/2023

The following were observed/inspected:

· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote hand washing, cough/sneeze etiquette, and physical distancing.
· Facility has one designated isolation room.
· 6 client rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· Six (6) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were observed wearing masks.
· Clients were not observed wearing masks but adhering to public health social distance guidelines.
· Sufficient supply of perishable food for 2 days & non-perishable foods for 7 days were observed.
· A posted Emergency Disaster Plan was observed and posted at the facility.
· PPE's were observed.
· Staff and resident files were not reviewed during today's visit.

10:47 am LPA and Administrator Leilani Pascasio observed broken facet for 1 shower and water temperature in that restroom was measured at 89.9 degrees F for shower and 67.1 degrees F for the sink. This bathroom in adjacent to the laundry room.
Deficiencies cited per Title 22 Health and safety code, please see 809D for details.

Exit interview was conducted with Administrator Leilani Pascasio. A copy of the report was provided.

SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022

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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Document Has Been Signed on 02/08/2022 12:59 PM - It Cannot Be Edited

Created By: Alberto Lopez On 02/08/2022 at 12:16 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-WASHINGTON	FACILITY NUMBER: 198601057
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

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
1 2 3 4	Based on observation and measurement of water temperture.The bathroom shower was (89.9 degrees F) and the sink was 67.1 degrees F in the same bathroom adjecent to laundry room at 10:47 am .The licensee did not comply with the section cited above in 2 of 2 counts which poses an immediate health, safety or personal rights risk to persons in care. Administrator Leilani Pacasio oberved the temperture readings.
	POC Due Date: 02/09/2022
	Plan of Correction
1 2 3 4	Administrator will adjust and monitror the water temperture in the shower and sink for seven days and send photo evidence and certifcation to LPA by POC date.

Type A

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
1 2 3 4	Based on observation the licensee did not comply with the section cited above in 1 0f 1 count. The shower handle was loose and falls off which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/09/2022
	Plan of Correction
1 2 3 4	Administrator will replace the facet for the shower and send receipt and photo evidence that it has been repalced and operable.

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:

Alberto Lopez

LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022

LIC809 (FAS) - (06/04)

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