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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004295
Report Date: 08/03/2023
Date Signed: 08/03/2023 05:02:34 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/24/2023 and conducted by Evaluator Jessica Cho
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230524163541

FACILITY NAME:NELDYS ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
306004295
ADMINISTRATOR:JON NEIL CASTROFACILITY TYPE:
735
ADDRESS:11411 STANFORD AVENUETELEPHONE:
(714) 539-5151
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY:6CENSUS: 5DATE:
08/03/2023
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Jon Castro- AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Dishwasher is dirty.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jessica Cho arrived unannounced to deliver the findings into the above allegation and for Complaint Control #’s: 22-AS-20230525121713 and 22-AS-20230523133515. LPA met with Administrator Jon Castro after stating the purpose of the visit. During the course of the investigation, LPA toured the kitchen which revealed the following:

It was alleged that the dishwasher is dirty. On May 30, 2023, during the initial 10-day inspection, LPA along with Staff #2 (S2) observed mold and rust accumulated in the dishrack at 4:48pm.
Therefore, based on LPA's observations, the preponderance of evidence standard has been met, therefore the above allegation is deemed SUBSTANTIATED as per Title 22, Division 6, Chapter 1 of the California Code of Regulations. A deficiency is being cited on the attached LIC 9099-D.
An exit interview was conducted with Administrator Jon Castro, and a copy of this report including the LIC9099-D and LIC811 were provided during today’s visit.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 22-AS-20230524163541
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: NELDYS ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 306004295
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/10/2023
Section Cited
CCR
80087(a)
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80087 Building and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement was not met as evidenced by:
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Facility to clean and to maintain the dishwasher at all times and to provide proof to LPA via email by POC due date.
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Based on LPA’s observations along with S2, the dish rack was not clean and sanitary on 05/30/2023 which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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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.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6