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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004295
Report Date: 03/24/2025
Date Signed: 03/24/2025 11:54:20 AM

Document Has Been Signed on 03/24/2025 11:54 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:NELDYS ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
306004295
ADMINISTRATOR/
DIRECTOR:		JON NEIL CASTROFACILITY TYPE:
735
ADDRESS:11411 STANFORD AVENUETELEPHONE:
(714) 539-5151
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY: 6CENSUS: 4DATE:
03/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:10 AM
MET WITH:Paul Arcinas- Lead StaffTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
NARRATIVE
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Licensing Program Analysts (LPA) Nancy Guillen conducted this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by Lead Staff Paul Arcinas after explaining the purpose of the visit. Administrator was not present for the annual inspection. LPA observed Administrator certificate is current with an expiration date of February 26, 2026. This is an Adult Residential Facility licensed for six developmentally disabled adults of which four may be ambulatory and two may be non-ambulatory. Four clients reside at this facility. LPA was informed all four clients were away at their day programs. At the time of visit there were no clients present.

LPA began the tour of the inside and outside of the facility and observed the following:
This is a two story facility with only the bottom portion available for client use. There are four client bedrooms, one staff room, three bathrooms, two living rooms, a kitchen, laundry room, dining room, and two attached garages. LPA observed required department postings posted on the wall at the entrance of the facility. Facility stays within the capacity limitations. There is a minimum of one week of non-perishable foods and two days of perishable foods available. There is additional food storage at the end of the hallway in an additional fridge and additional emergency food in a hallway storage closet. The facility is maintained at a comfortable temperature. LPA observed that medication is centrally stored in a locked storage cabinet located in a hallway closet. LPA reviewed medication and observed medication was labeled and stored inaccessible to clients in care. LPA inspected the bathrooms and LPA measured the hot water temperature which measured 114.9 to 118.7 degrees Fahrenheit.

Continued on 809C
NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Nancy Guillen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2025
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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Document Has Been Signed on 03/24/2025 11:54 AM - It Cannot Be Edited


Created By: Nancy Guillen On 03/24/2025 at 10:57 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 03/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in one out of three staff records reviewed due to Staff #2 not having a negative TB test on file, which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/25/2025
Plan of Correction
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Lead Staff stated Staff #2 will have TB test by tomorrow and Lead Staff will email LPA a copy by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Nancy Guillen
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2025


LIC809 (FAS) - (06/04)
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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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: NELDYS ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 306004295
VISIT DATE: 03/24/2025
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All bathrooms observed to have a supply of soap, toilet paper and towels. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored under the kitchen sink and in the laundry room. The facility has an available clean supply of linens in a hallway closet. LPA inspected client’s bedrooms which have sufficient lighting to ensure the safety and comfort of clients in care. All bedrooms observed to have all required components. Storage space is provided for clients in their bedroom. Smoke detectors and carbon monoxide detector were tested and found to be operational. LPA toured the outside of the facility and observed outdoor passageways were free of obstructions. LPA observed there was not a shaded seating area outdoors for client use, a technical violation was issued on today’s date. LPA observed a fire extinguisher with service date of April 18, 2024 in the primary living room near the kitchen. Disaster drills are conducted monthly with the last drill conducted on March 1st 2025. LPA began review of records. LPA reviewed four clients’ records. All the required documentation was present and current in client’s files reviewed. The facility P&I records were reviewed. LPA observed that an individual log is maintained for each client. All monies are accounted for and attached receipts for record keeping. LPA reviewed three employee records. All employees present have a criminal record clearance and are associated to the facility. LPA observed records reviewed have a current First Aid certificate. LPA observed Staff # 2 did not have a negative TB test on file; a deficiency was cited on today’s date.

Based on the observation made during today’s visit, a deficiency is being cited per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with the Lead Staff and a copy of this report, LIC809C, LIC 809D, and Appeal Rights was provided and left at the facility.
NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Nancy Guillen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
LIC809 (FAS) - (06/04)
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