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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 03:07:40 PM

Document Has Been Signed on 08/16/2023 03:07 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:POCUNANNOUNCEDTIME BEGAN:
02:12 PM
MET WITH:Marites Simbulan- Administrative AssistantTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Jessica Cho arrived unannounced to follow up on the Plan of Corrections (POCs) issued after observing a deficiency which were cited during the case management and complaint investigation visits (for Complaint Control #: 22-AS-20230524163541) held on August 3, 2023.
Administrator Jon Castro consented Administrative Assistant (AA) to sign the report on his behalf after explaining the reason of the visit.

On today's date, LPA observed that the dishwasher was clean and sanitary and the medication cabinet was properly secured. Administrator complied with the terms of the POCs; and as a result, LPA cleared two citations issued on August 3, 2023.

An exit interview was conducted with Administrative Assistant Marites Simbulan, and a copy of this report including the two POC clearance letters were sent to Administrator Jon Castro via email.
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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