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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601057
Report Date: 12/30/2025
Date Signed: 12/30/2025 04:07:32 PM

Document Has Been Signed on 12/30/2025 04:07 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:
12/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Leilani Pascasio, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced annual visit today. Rose Baltazar, Direct Support Professional, granted entry to the home and the reason for the visit was explained. Leilani Pascasio arrived thereafter and continued to assist with the visit.

The home is licensed to serve (6) developmentally disabled adults ages 18 through 59 years of age; (6) can be non-ambulatory. The home is operating within the scope of its license. There are currently (6) clients living in the facility. The home is in a residential area of Pasadena. The two-story home consists of living room, dining room, kitchen, staff office, laundry area, (4) client bedrooms (which two are shared), (3) full bathrooms, food storage room, side patio area, front and backyard. The second story of the home is not being used by staff or clients. The second floor is off limits and entry way and staircase was observed locked during today’s visit.

During today’s visit, LPA observed the following:

The facility is clean inside and out. Passageways, walkways and exits are free of debris and obstructions. Furniture in the home is in good repair and there is enough seating area in the living room and dining area for clients in care. The kitchen is clean, and appliances are operational. The home has sufficient (7) day non-perishable and (2) day perishable supply of food which is kept within expiration limits. The food is properly stored and labeled. Sharps/knives are kept locked in a kitchen drawer and are inaccessible to clients in care. The bedrooms have the required furnishing and bedding. Linnen is clean and in good repair. The home keeps extra bedding and towels in the hallway closet. The bathrooms are also kept clean and sanitary. Closets are spacious and kept organized. The water was tested in the three bathrooms and measured between 105.5-106.3 degrees F., which is within compliance range. The laundry area is clean, and the appliances are operable. Detergents are kept locked in the storage room. The facility’s fire extinguisher is kept charged and in operable condition.

***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: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2025
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 3
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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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: 12/30/2025
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The home has combination, interconnected smoke and carbon monoxide detectors which were tested and observed to be working properly. The home is also equipped with a sprinkler system which was serviced by Pasadena Fire Marshall on 7/29/2025 (annual required inspection). The food storage room, which is accessed through the backyard, is clean and kept locked. An emergency supply of food and water is kept, along with an overflow refrigerator and freezer which is kept stocked with staff and client food. Garden is well maintained. A patio area is available, and patio furniture is in good repair.

LPA reviewed (4) client and (4) staff files. Client and staff files contain the mandated documents. Safety drill records were also reviewed. The home conducts drills every quarter.

Medication is centrally stored and locked in medication closet in the staff office. Medication review was conducted and found to be dispensed according to physician’s orders and documented accordingly.

During today’s visit, no deficiencies were noted, and no citations issued per Title 22 Regulations. Exit interview was conducted with Leilani Pascasio, Administrator, and a copy of this report was provided.

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

DATE: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025
LIC809 (FAS) - (06/04)
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