198601057-1-25-2023-28-AS-BPEA-CNESUK-20230125131115

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601057
Report Date: 01/25/2023
Date Signed: 01/25/2023 01:11:29 PM

Document Has Been Signed on 01/25/2023 01:11 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-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:	01/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Administrator, Nelia Pascasio		TIME COMPLETED:	01:30 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) Bennette Pena conducted an unannounced annual inspection focusing on the Infection Control Domain. LPA arrived at the facility and rang the doorbell many times and knocked on the door but no one answered. LPA called the Administrator Hermenia delaCruz to inform her that LPA was at the door. A few minutes later, I was allowed entry into this home by Jenneth Liwag, Direct Support Professional/DSP and discussed the purpose of today's visit. LPA observed that the doorbells in the front and side door of the facility were not working. At 11:30am Nelia Pascasio, the Administrator arrived and assisted with the inspection. The facility is licensed to care for six (6) Developmentally Disabled Adults, ages 18-59, non ambulatory. This single-story home contains four (4) bedrooms, three (3) bathrooms, office, living room, kitchen, dining area, backyard, and detached garage. The following was observed/inspected: The facility had a universal entrance screening area including a thermometer, PPE supplies, screening logs, and sign-in sheet. COVID-19 signage was placed in several areas of the facility. Staff wore face masks throughout their shift. Facility maintained a 30-day supply of PPE located in the supply closet and garage. The laundry room is clean and has cleaning supplies inaccessible to residents. The kitchen was inspected. LPA observed that some cleaning solutions were inside the unlocked kitchen cabinet under the sink. DSP Imelda Chan removed the items and stored them away in a locked cabinet. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All the appliances are clean and working properly. LPA observed a few expired food items that were stored inside the refrigerator. DSP Jenneth Liwag removed and threw the items away. Cleaning solutions, laundry soaps, kitchen knives and sharps were locked in a cabinet and inaccessible to clients. Hot water temperature was measured in kitchen and bathrooms. Kitchen water temperature read 111.6 degrees F. Bathroom #1 read at 113.2 deg. F, bathroom #3 read at 115.5 deg F. The hot water is within the required 105 - 120 degrees. *Refer to LIC 809C for the continuation of this report.*

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

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-WASHINGTON	FACILITY NUMBER: 198601057
	VISIT DATE: 01/25/2023

NARRATIVE

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Clients bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, night stand, light, chair and sufficient closet space.
Bathrooms have the required grabs bars, non-skid materials and contained hygiene supplies including liquid soap, paper towels, and toilet paper.
Medications were locked, centrally stored, and given as prescribed. Medications were reviewed for all clients and found deficiencies as medications for some clients were administered but not documented properly on Medication Administration Record (MARs).
The common areas such as living room and dining room are clean and have the required furniture. Furniture and group activities were spaced to encourage physical distancing.
The backyard has a shaded area and sitting area. The backyard has been designated as the visitor area during the COVID-19 pandemic.
Smoke detectors/carbon monoxide detectors were present and operable.
A fire extinguisher was observed to be fully charged and last serviced on February 1, 2022. LPA advised Administrator to have the fire extinguishers inspected before Feb. 1, 2023, or they can purchase new ones.
Clients and staff files were not reviewed during today's visit.

Pursuant to Title 22, deficiencies were cited on the attached 809D and Technical Assistance were issued. An exit interview was conducted, and a copy of this report was provided to the Administrator, Nelia Pascasio.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/25/2023 01:11 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80075(b)(5)(C)

Health-Related Services

(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (C) A record of each dose is maintained in the client's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the client's response. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the Administrator did not comply with the section cited above in which the medication record for (4) out of (6) clients were not documented properly, such as: PM/Evening medications were administered but the MARs were not signed/initialed, PRN medications that were not discontinued were not listed on the MARs, and PM/Evening medications were not given but MARs were signed/initialed stating they were administered which pose an immediate health, safety or personal rights risk to clients in care.
	POC Due Date: 01/26/2023
	Plan of Correction
1 2 3 4	Administrator will ensure to get proper medication training for the staff and obtain correct Medication Administration Record for all the clients to include PRNs. Administrator will submit a copy of the medication trainings for staff and updated/corrected MARs on or before the POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

LIC809 (FAS) - (06/04)

Page: 3 of 6

Document Has Been Signed on 01/25/2023 01:11 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/25/2023

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
1 2 3 4	Based on observation, interview, the Administrator did not comply with the section cited above in which the doorbells for both entry points in the facility, front and side doors were inoperable. LPA tested the doorbells and observed that both were not ringing or chiming when the buttons were pressed which posed a potential health, safety or personal rights risk to clients in care.
	POC Due Date: 02/08/2023
	Plan of Correction
1 2 3 4	Administrator will send photos, receipts and/or service orders of the newly installed or repaired doorbells to the LPA on or before the POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

LIC809 (FAS) - (06/04)

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