306004295-4-27-2023-22-AS-SSAS-CREU3G-20230501151332

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004295
Report Date: 04/27/2023
Date Signed: 04/27/2023 04:45:37 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/14/2023 and conducted by Evaluator Jessica Cho

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230414131801

FACILITY NAME:	NELDYS ADULT RESIDENTIAL CARE HOME		FACILITY NUMBER:	306004295
ADMINISTRATOR:	JON NEIL CASTRO		FACILITY TYPE:	735
ADDRESS:	11411 STANFORD AVENUE		TELEPHONE:	(714) 539-5151
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92840
CAPACITY:	6	CENSUS: 5	DATE:	04/27/2023
		UNANNOUNCED	TIME BEGAN:	02:43 PM
MET WITH:	Jon Castro		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff did not safeguard client's personal property.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit for the purpose to conduct a complaint investigation. At 2:47pm, LPA notified Administrator Jon Castro by telephone who then notified the on duty staff to open the door. LPA was granted entry by Care Staff Myrna Cabaneros after stating the purpose of the visit. During the course of the investgation, LPA interviewed clients, staff, and Administrator. Copies of records were obtained and reviewed during the visit, and the following was determined:

On the allegation that staff did not safeguard client's personal property, it was alleged that new leggings purchased for Client 1 (C1) including various personal items owned by the clients have gone missing. Interviews with three out of five clients indicated that they experienced theft by Client 4 (C4) which was addtionally confirmed by five out of six individuals. With regards to staff safeguarding client's personal property, two out of five clients expressed that the staff ensures that their room is being monitored while three out of six individuals indicated that they did not have a procedure to keep track and safeguard the

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20230414131801

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 HOME	FACILITY NUMBER: 306004295
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/27/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/04/2023 Section Cited CCR 80026(b)	1 2 3 4 5 6 7	80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents(b) If such a client is accepted for or maintained in care, his/her cash resources, personal property, and valuables... shall be handled by the licensee or facility staff, and shall be safeguarded in accordance with the requirements specified in (c) through (n) below.	1 2 3 4 5 6 7	Licensee to review the complete regulation for 80026 and to forward a Acknowledgement of Understanding in writing in addition to providing a log for each of the clients' personal items.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on the interviews and records reviewed, facility did not have a procedure to safeguard the clients' personal items which poses a potential Health, Safety, and Personal Rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20230414131801

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 HOME	FACILITY NUMBER: 306004295
	VISIT DATE: 04/27/2023

NARRATIVE

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items of the clients. One out of the six individuals interviewed was unable to comprehend and answer the question.

Based on the interviews and the records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is deemed SUBSTANTIATED. A deficiency is being cited as per Title 22, Division 6, Chapter 1 of the California Code of Regulations, Title 22, Division 6, Chapter 1. See LIC 9099D.

An exit interview was conducted with Administrator Jon Castro, and a copy of this report including the LIC9099C, LIC811, LIC9099D were provided during today's visit.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

LIC9099 (FAS) - (06/04)

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