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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602064
Report Date: 09/25/2025
Date Signed: 09/25/2025 01:59:59 PM

Document Has Been Signed on 09/25/2025 01:59 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 - SHRODEFACILITY NUMBER:
198602064
ADMINISTRATOR/
DIRECTOR:		RIA TABUCALFACILITY TYPE:
735
ADDRESS:134 SHRODE AVETELEPHONE:
(626) 599-9330
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY: 4CENSUS: 4DATE:
09/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Johaira Mimbala, DSPTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Daniel Konishi 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 explained the purpose of the visit. Shortly after, Administrator Ria Tabucal and Licensee, Glorie Pascasio 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.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and 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 an updated Infection Control Plan in place. Staff are adhering to infection control requirements.

Operational Requirements: The fire clearance is in place. The facility has a valid Liability Insurance policy in place. The facility has a valid Surety Bond in place. Fire Drill was last conducted on 09/14/2025. The Earthquake/Disaster drill was conducted on 09/15/2025 Clients PNI records reviewed, no discrepancies noted.

Physical Plant/Environment Safety: The facility is a single-story home located in a residential neighborhood, containing 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. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, nightstand, light, chair and sufficient closet space. Beds and furnishings are in good working condition.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2025
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 4
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 - SHRODE
FACILITY NUMBER: 198602064
VISIT DATE: 09/25/2025
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Clean and additional linens and towels are located in the hallway closet. The two (2) bathrooms were clean and contained a working toilet, basin, and water faucet, walk in shower with non-skid mats. LPA reviewed and measured hot water temperature in bathroom #1 at 108.6 degrees F and bathroom #2 at 113.9 degrees F which were within the required 105-120 degrees Fahrenheit. Exit doors are free of any obstruction and there are no pools or large bodies of water. Attached garage was inspected and there is an extra freezer stocked with additional food items. Cleaning supplies are locked in the cabinet at the garage and inaccessible to clients. Kitchen knives, sharps objects, are kept locked in a kitchen drawer. There are one (1) fire extinguisher in the kitchen which is fully charged and was last inspected on 03/31/2025. Carbon monoxide was tested and operable. There are no firearms or weapons stored at the facility. Backyard was inspected and has a shaded area and sitting area.

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 are associated to the facility.

Personnel Records/Staff Training: LPA reviewed four (4) staff files that include: personnel record, staff training, health clearance, employee rights, and 1st Aid/CPR/AED training. Administrator certificate is valid and will expire on 05/07/2026. Administrator has valid HIV and TB training in file.

Client Rights-Information: Client personal rights are posted. Facility provides internet services to all clients and have access to the facility phone.

Food Service: Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. 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 modified diets. Pesticides and cleaning supplies are kept away from the food preparation areas. Plates, cups and utensils are kept clean and stored properly.

Client Records-Incident Reports: LPA reviewed four (4) client files which include Face Sheet, Physician's Report (including TB and Ambulatory Status), Individual Program Plan (IPP), Behavioral Reports, and Clients Personal Rights observed.

Health Related Services: The medications are centrally stored and in their original containers. LPA reviewed four (4) client files to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are given according to Physician directions.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
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 - SHRODE
FACILITY NUMBER: 198602064
VISIT DATE: 09/25/2025
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Incidental Medical Services: Per the Administrator, there is no clients with restricted health conditions. LPA reviewed the First Aid Kit which has all required items. The facility provides transportation to medical and dental appointments.

Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least two (2) relocation sites. The last fire/earthquake drill was conducted on 08/29/2025.

Emergency Intervention: Clients at this facility do not need the use of restraints or de-escalation techniques.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview and a copy of this report were provided to the Administrator, Ria Tabucal.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
LIC809 (FAS) - (06/04)
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