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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602064
Report Date: 08/27/2024
Date Signed: 08/27/2024 04:26:31 PM

Document Has Been Signed on 08/27/2024 04:26 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 - SHRODEFACILITY NUMBER:
198602064
ADMINISTRATOR/
DIRECTOR:		RIA TABUCALFACILITY TYPE:
735
ADDRESS:134 SHRODE AVETELEPHONE:
(626) 599-9330
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY: 4CENSUS: 4DATE:
08/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Ria Tabucal - AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Joan Mimbala, Direct Service Professional I & II (DSP I & II) and explained the purpose of the visit. Shortly after, Administrator Ria Tabucal arrived and assisted LPA with the inspection. The facility is licensed to care for four (4) Developmentally Disabled Adults, ages 18 through 59, ambulatory only. Three (3) clients residing at this facility receive case management services provided by San Gabriel Pomona Regional Center and one (1) byFrank D. Lanterman Regional Center. LPA observed the following:
Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located near the front door.The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Staff are adhering to infection control requirements.
Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. Liability Insurance policy in the amount of $1,000,000.00 each occurrence and $3,000,000.00 in the total annual aggregate is valid and expires on 09/17/2024. Surety Bond is in effect with bond amount of $3000 and expires on 10/03/2025. Fire/Disaster Drill was last conducted on 04/09/2024. Clients PNI records reviewed, no discrepancies noted.
Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood, contains four (4) client bedrooms, two (2) full bathrooms, living room, kitchen, dining area, backyard, and attached garage. Currently, there are four (4) clients living in the facility. Facility is a Level 4I. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, night stand, light, chair and sufficient closet space. Bathrooms have non-skid materials and contained hygiene supplies. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and has a shaded area and sitting area. LPA observed black plastic bags overflowing with recycling plastic bottles next to the shed. Attached garage was inspected and there is an extra freezer stocked with additional food items. Kitchen knives, sharps objects, are kept locked in a kitchen drawer. There are two (2) fire extinguishers in the facility which were last serviced on 12/05/2023. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature readings were within the required 105-120 degrees Fahrenheit.
*****CONTINUED ON LIC809-C*****
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2024
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: NELVILLE GUEST HOME - SHRODE
FACILITY NUMBER: 198602064
VISIT DATE: 08/27/2024
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Staffing: A total of eleven (11) staff members including the Administrator provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.
Personnel Records/Staff Training: Reviewed files for three (3) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate is valid and will expire on 05/07/2026.
Client Rights-Information: Client personal rights are posted. Facility provides internet services to all clients and have access to the facility phone. One (1) client has a personal cell phone and no one has Ipad/tablets.
Food Service: There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator. There are zero (0) client with special diets residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.
Client Records-Incident Reports: LPA reviewed Client files for C1 through C4. Client files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.
Health Related Services: The medications are centrally stored and in their original containers. Medications were reviewed for C1-C4 to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA observed that one of S4's medication (Vit. D3 2000 unit) was still in the bubble pack and not given, but staff documented/initialed the Medication Administration Record (MAR) as administered.
Incidental Medical Services: Per the Administrator, there is no client at this home with incidental medical services nor have a restricted health condition.
Disaster Preparedness: The facility does have a complete Emergency Disaster and Mass Casualty Plan. Emergency Intervention: Not-Applicable.

Deficiency cited on LIC 809D and Technical Assistance issued.

Exit interview, appeals rights and a copy of this report was provided to the Administrator, Ria Tabucal.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/27/2024 04:26 PM - It Cannot Be Edited


Created By: Bennette Pena On 08/27/2024 at 01:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: NELVILLE GUEST HOME - SHRODE
FACILITY NUMBER: 198602064

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(6)(C)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (6) If the client is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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) The date and time the PRN medication was taken, the dosage taken, and the client's response, shall be documented and maintained in the client's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, the Administrator did not comply with the section cited above in which one of S4's medication (Vit. D3 2000 unit) was still in the bubble pack and not given, but staff documented/initialed the Medication Administration Record (MAR) as administered which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 08/28/2024
Plan of Correction
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Administrator will conduct in service Medication Administration Training and a Medication Verification method in which a secondary staff verifies and ensures medication has been administered as prescribed. During the visit, the prescribing Physician was notified of the medication error. In service medication logs will be submitted to CCL/LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024


LIC809 (FAS) - (06/04)
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