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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004295
Report Date: 08/16/2023
Date Signed: 08/16/2023 02:09:11 PM

Document Has Been Signed on 08/16/2023 02:09 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
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:
08/16/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:56 AM
MET WITH:Jon Castro- AdministratorTIME COMPLETED:
02:11 PM
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Licensing Program Analyst (LPA) Jessica Cho arrived unannounced to conduct a case management visit to deliver an amended report for a visit conducted on August 3, 2023 from 12:32pm to 4:30pm in connection to Complaint Control #: 22-AS-20230523133515.

During today's visit, LPA Cho met with Administrator (Admin) Jon Castro and explained the reason for the visit. LPA reviewed all medications including the Medication Administration Records and conducted an interview with Staff #6 (S6). LPA addressed the changes on the amended report with Administrator Castro.

An exit interview was conducted with Administrator Jon Castro, and a copy of this report along with the amended complaint report (LIC9099, LIC9099-C, LIC811) were provided to the Administrator via email during the visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2023
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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