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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602064
Report Date: 02/16/2024
Date Signed: 02/16/2024 11:50:42 AM

Document Has Been Signed on 02/16/2024 11:50 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:
02/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Administrator Glorie PascasioTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Administrator Glorie Pascasio and the purpose of the visit was discussed. The following (CARE) tool domains were utilized during the inspection:

Infection Control:
  • Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. The facility has an Infection Control Plan for LPA to review.

Operational Requirements:
  • A current Plan of Operation was reviewed.
  • A fire clearance for Four (4) Ambulatory clients only.

Physical Plant/Environment Safety:
  • The facility is located in a residential area. The facility has 4 bedrooms, 2 bathrooms, living room, dining area, kitchen, and attached garage
  • The physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to clients
  • Fire Alarms were inspected. Fire extinguishers Observed
  • Water temperature readings measured within the required 105 - 120 degrees Fahrenheit.

Staffing
  • Sufficient staff observed to meet clients needs
  • Facility currently provides care and supervision for a total of four (4) Clients.

Continued on LIC 809-C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 - SHRODE
FACILITY NUMBER: 198602064
VISIT DATE: 02/16/2024
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Personnel Records-Training:
  • Administrator on record is current
  • Staff have criminal background clearance and training.
  • Four (4) staff files were reviewed. Proof of staff training, health clearance, and 1st Aid/CPR and CPI training was observed. Staff file have criminal record clearances and are associated.

Client Records-Incident Reports:
  • A total of Four (4) client files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment / IPPs, Physician's Orders, medical consent, and medication records.

Client Rights-Information
  • No postural Supports Observed
  • Internet source provided to clients in care. Required postings observed.

Planned Activities:
  • Sufficient space to accommodate both indoor and outdoor activities was observed.
  • An activity calendar was reviewed

Food Service:
  • Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies observed.
  • Sanitation practices and kitchen cleanliness was observed.

Incident Medical and Dental:
  • Four (4) Client centrally stored medications were reviewed.
Disaster Preparedness:
  • Emergency and Disaster Plan LIC 610 is in place.
Clients with Special Health Needs:
  • Individual Service Plans and Appraisals are on file. No residents have prohibited health conditions.


All (12) domains have been completed as of todays visit. Per California Code of Regulations, Title 22, No deficiencies are being cited. Exit Interview Conducted and a copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
LIC809 (FAS) - (06/04)
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