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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601057
Report Date: 01/28/2025
Date Signed: 01/28/2025 12:41:10 PM

Document Has Been Signed on 01/28/2025 12:41 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-WASHINGTONFACILITY NUMBER:
198601057
ADMINISTRATOR/
DIRECTOR:		PASCASIO, NELIAFACILITY TYPE:
735
ADDRESS:1250 EAST WASHINGTON BLVD.TELEPHONE:
(626) 791-2665
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 6DATE:
01/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Administrator, Leilani PascasioTIME VISIT/
INSPECTION COMPLETED:
11:28 AM
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Licensing Program Analyst (LPA) S Vaid conducted an unannounced 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Leilani Pascasio, administrator who assisted with the visit. There are six (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 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. 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.
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 12 (10) full-time and 2 part time staff members provide care and supervision to the clients.

Continued on 809C........
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: NELVILLE GUEST HOME-WASHINGTON
FACILITY NUMBER: 198601057
VISIT DATE: 01/28/2025
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5. Personnel Records/Staff Training: Administrator’s certificate expired 03/04/2025, renew was sent in January 2025 in process. 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 drills, fire /earthquake was last documented on 01/20/2025.
12. Emergency Intervention: No manual restraints or seclusion are used with clients in care.

No deficiencies observed during today’s visit. Exit interview held and a copy of the report were provided to Administrator.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
LIC809 (FAS) - (06/04)
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