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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004295
Report Date: 04/26/2023
Date Signed: 04/26/2023 12:52:09 PM

Document Has Been Signed on 04/26/2023 12:52 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:
04/26/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:24 PM
MET WITH:Rina Bognot - staff TIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Celine De Perio conducted a case management visit in conjunction to complaint: 22-AS-20230418101613 and explained reason to staff on duty (S1) Rina Bognot.

During the 10-day visit initiated on 4/26/23, upon entry of the facility, LPA observed a couch in the living room, that had an exposed hole, and no topper.

(SEE LIC809-D).

For this visit, a citation was issued per Title 22 California Code of Regulations.

An exit interview was conducted with S1 and a copy of this report was explained and provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 04/26/2023 12:52 PM - It Cannot Be Edited


Created By: Celine DePerio On 04/26/2023 at 12:36 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: 04/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/03/2023
Section Cited
CCR
80087(a)

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80088 Furniture, Fixtures, Equipment, and Supplies
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This requirement is not met as evidence by:
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As plan of correction (POC) facility will provide proof of understanding regarding the regulation cited, and will ensure that the furniture in the facility is in good repair. Facility will provide proof to Community Care Licensing (CCL) and assigned LPA on or by 5/3/23.
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Based on observation and interviews conducted, facility failed to ensure that the facility...is in good repair...
LPA observed a couch in the living room with an exposed hole, and without a mattress topper. This poses a potential health and safety 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:Luz Adams
LICENSING EVALUATOR NAME:Celine DePerio
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023


LIC809 (FAS) - (06/04)
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