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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004295
Report Date: 04/05/2023
Date Signed: 04/05/2023 12:46:12 PM

Document Has Been Signed on 04/05/2023 12:46 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:
04/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Paul ArcinasTIME COMPLETED:
01:00 PM
NARRATIVE
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This unannounced inspection is being conducted by Licensing Program Analysts (LPAs) Sean Haddad and Dwayne Mason for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20230113172123. LPAs met with Staff #1 (S1) Paul Arcinas 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, LPAs inspected client money and ledgers for 5 clients and observed the cash resources and ledger for Client #1 (C1) did not match as the cash resources were short approximately 11 dollars as counted and confirmed by Staff #2 (S2) Fe Garcia.

Based on the observations and documents obtained 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: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2023
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 04/05/2023 12:46 PM - It Cannot Be Edited


Created By: Sean Haddad On 04/05/2023 at 12:32 PM
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: 04/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/06/2023
Section Cited
CCR
80026(h)(1)

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80026 Safeguards for Cash Resources… (h) Each licensee shall maintain accurate records of accounts of cash resources …: (1) Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting …. This requirement was not met as evidenced by:
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Licensee stated they will review Section 80026 and submit to LPA a plan outlining how the facility will safeguard client cash resources moving forward by POC due date.
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Based on observations and documents, the licensee did not ensure 1 out of 5 client cash resources matched their ledgers, which poses a personal rights risk to clients 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: 04/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2023


LIC809 (FAS) - (06/04)
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