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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004295
Report Date: 01/17/2023
Date Signed: 01/17/2023 11:05:58 AM

Document Has Been Signed on 01/17/2023 11:05 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:
01/17/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Nona BarabonaTIME COMPLETED:
11:15 AM
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20230113172123. LPA met with Staff #1 (S1) Nona Barabona and explained the reason for today’s inspection. Administrator (AD) Jon Neil Castro was not present during the inspection.

During the course of the investigation, Staff #2 (S2) Paul Arcinas revealed that during a recent facility trip to Big Bear, clients and staff traveled in the facility vehicle which can only seat 8 people and to fit the 9 individuals 2 staff had to share a seat and a seatbelt. S2 stated it was an isolated incident.

Based on the interviews conducted during the investigation, violations are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2023
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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Document Has Been Signed on 01/17/2023 11:05 AM - It Cannot Be Edited


Created By: Sean Haddad On 01/17/2023 at 11:02 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: 01/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/18/2023
Section Cited
CCR
80074(b)

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80074 Transportation … (b) The manufacturer's rated seating capacity of the vehicles shall not be exceeded. This requirement was not met as evidenced by:
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Licensee stated it was an isolated incident. Licensee agreed to create and submit to LPA by 01/24/23 a transportation policy detailing seating capacities, designated drivers, proper insurance coverage, etc.
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Based on interviews, the licensee did not ensure the seating capacity of the facility’s vehicle was not exceeded on a recent trip to Big Bear, which poses an immediate health and safety risk to residents 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.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023


LIC809 (FAS) - (06/04)
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