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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602064
Report Date: 10/20/2021
Date Signed: 10/21/2021 07:38:25 AM

Document Has Been Signed on 10/21/2021 07:38 AM - 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 - SHRODEFACILITY NUMBER:
198602064
ADMINISTRATOR:GLORIE PASCASIOFACILITY TYPE:
735
ADDRESS:134 SHRODE AVETELEPHONE:
(626) 599-9330
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY: 4CENSUS: 4DATE:
10/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Staff / Ria Tabucal & Joan Mimbala
Administrator / Glorie Pascasio
TIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced site visit for the Required - 1 Year inspection. Upon arriving at the facility, LPA met with Staff Members / Ria Tabucal and Joan Mimbala and was later joined by the Administrator / Glorie Pascasio who assisted with the visit. The facility is licensed to serve four (4) Developmentally Disabled adults ages 18 through 59 years old. Approved for four (4) Ambulatory clients only. During today's visit, LPA used the infection control domain to complete the Required - 1 Year inspection. Also, the physical plant was toured, medication and food supplies reviewed.
The facility is located in a residential area. A tour of the single-story facility includes: Four (4) client bedrooms, two (2) bathrooms, living room, kitchen / dining area, laundry room and indoor/outdoor activity areas. All medications for residents who need assistance are kept locked and inaccessible to other clients. Knives, disinfectants and cleaning solutions are kept locked and inaccessible to clients. The bathrooms are clean and operational. Client bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The hot water temperature was tested throughout the facility and measured within Title 22 Regulation guidelines. The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. LPA reviewed client medications.
Smoke detectors and carbon monoxide detectors are operable and in compliance. LPA observed a pull-switch fire alarm behind the entrance door. The fire extinguishers (2) were fully charged and in compliance. The first-aid kit is fully stocked w/First-aid Manual. The front yard is well landscaped with steps and/or a ramp that leads to the entry. A shaded area with chairs is provided in the back yard. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. The trash cans have covered lids. There is no evidence of bodies of water (pool) or security bars nor weapons on the premises. The attached garage is kept locked and inaccessible to clients at all times.

No deficiencies were observed during this visit
An exit interview was conducted and a copy of this report was provided to the Administrator.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2021
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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