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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601057
Report Date: 01/09/2024
Date Signed: 01/09/2024 04:19:34 PM

Document Has Been Signed on 01/09/2024 04:19 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-WASHINGTONFACILITY NUMBER:
198601057
ADMINISTRATOR:PASCASIO, NELIAFACILITY TYPE:
735
ADDRESS:1250 EAST WASHINGTON BLVD.TELEPHONE:
(626) 791-2665
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 6DATE:
01/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:Rosa Baltazar, Leilani Pascasio, Assistant Administrator. TIME COMPLETED:
04:39 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Leilani Pascasio, assistant administrator who assisted with the visit. There are one (6) ambulatory developmentally disabled clients who reside in the home. The facility is vendored through Frank D Lanterman Regional Center.

The following was observed:

1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Facility is disinfecting throughout the day.

2. Physical Plant/Environment Safety: The facility is a two-story home located in a residential neighborhood that is licensed for a capacity of six (6) ambulatory developmentally disabled clients between the ages of 18-59, It consists of two (2) individual client bedrooms, two shared rooms, a living room, dining room, a kitchen, staff office, laundry area, 3 full bathrooms, a front and back patio area, and storage area for the facility. Hot water temperature measured between 79.8 – 123.4 Degrees which is not within range of 105-120 Degrees F. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Fire alarm system is operational. One bed needs repair or replacement. A retaining wall adjacent to the basketball court outside is cracked and need to be assessed to make sure it is structurally sound. The facility has four (4) fully charged fire extinguishers that are kept at the facility. Cleaning supplies and toxic substances are inaccessible to clients.

(Continued)

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2024
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 01/09/2024 04:19 PM - It Cannot Be Edited


Created By: Alberto Lopez On 01/09/2024 at 03:57 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-WASHINGTON
FACILITY NUMBER: 198601057

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2024

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
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Based on observation, the licensee did not comply with the section cited above. The water ranged from 79.8 degrees F to 123.4 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2024
Plan of Correction
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Administrator will adjust water and keep log for 7 days and will send it to LPA as proof.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/09/2024 04:19 PM - It Cannot Be Edited


Created By: Alberto Lopez On 01/09/2024 at 03:57 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-WASHINGTON
FACILITY NUMBER: 198601057

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
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.

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. The way in court yard is cracked and needs to be assessed for structural integrity. Which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2024
Plan of Correction
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Administrator will have wall assessed the wall for structural integrity and send proof to LPA by POC date
Type B
Section Cited
CCR
85088(c)(1)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (1) An individual bed, except that couples shall be allowed to share one double or larger sized bed, maintained in good repair, and equipped with good bed springs, a clean mattress and pillow(s).

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. Bed in one resident's room is in need of repair or replacement which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/09/2024
Plan of Correction
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Administrator will repair or replace the bed and send proof to LPA by POC 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.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024


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-WASHINGTON
FACILITY NUMBER: 198601057
VISIT DATE: 01/09/2024
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 3. Operational Requirements: The Program Design was reviewed. Fire clearance was approved by LA County Fire Department for three (6) ambulatory clients. Care and supervision to meet the clients’ needs was observed.
4) Staffing: A total of 10 (7) full-time and 3 part time staff members provide care and supervision to the clients.

5. Personnel Records/Staff Training: Administrator’s certificate expired 03/04/2025. Staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings and 1st Aid/CPR training.

6. Client Rights/Information: Personal rights are posted near the entrance.

7. Client Records/Incident Reports: Six (6) client files were reviewed containing admission agreements, Current IPP, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent.

8. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

9. Health Related Services: Clients are assisted with self-administration of prescription and non-prescription medications. Six (6) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked not accessible to clients in care. Medications are given according to Physician orders.

10. Incident Medical and Dental: All clients have a Needs and Services Plan, and COVID-19 vaccination cards on file.

11. Disaster Preparedness, and Emergency Intervention: A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed but needs to be update. An emergency drill was last documented on 09/09/2023.


12. Emergency Intervention: No manual restraints or seclusion are used with clients in care.


Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during the visit are documented on the LIC809D. Exit interview held and a copy of the report along with appeal rights were provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC809 (FAS) - (06/04)
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