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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004295
Report Date: 10/24/2023
Date Signed: 10/24/2023 11:24:59 AM

Document Has Been Signed on 10/24/2023 11:24 AM - 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:
10/24/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:24 AM
MET WITH:Facility Administrator - Jon CastroTIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 9099D on 10/10/2023 in conjunction to complaint control number: 22-AS-20230418101613

LPA De Perio explained reason for visit and was greeted and granted entry by facility administrator (AD) Jon Castro.

On 10/10/23, facility provided direct admission of having documents signed off by another individual. This poses an immediate health and safety risk to clients in care.*Deficiency cited under Title 22 Health and Safety Code 1550(c) pertaining to Licenses... has been CLEARED. Facility provided proof of understanding and has complied with the POC terms.

On 10/10/23, facility failed to ensure that each client shall have personal rights...to be accorded dignity in his/her personal relationships with staff and other persons. This poses a potential health and safety risk to clients in care.


*Deficiency cited under Title 22 California Code of Regulations 80072(a)(1) pertaining to Personal Rights has been CLEARED. Facility provided proof of understanding and has complied with the POC terms.

On 10/10/23, facility failed to ensure that each client shall have personal rights...to be free from corporal or unusual punishment...humiliation, intimidation, ridicule. This poses a potential health and safety risk to clients in care.
*Deficiency cited under Title 22 California Code of Regulations 80072(a)(3) pertaining to Personal Rights has been CLEARED. Facility provided proof of understanding and has complied with the POC terms.

An exit interview was conducted with AD Castro. A copy of this report was provided and explained.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2023
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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