<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004295
Report Date: 08/03/2023
Date Signed: 08/03/2023 05:24:07 PM

Document Has Been Signed on 08/03/2023 05:24 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:
08/03/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:05 PM
MET WITH:Jon Castro- AdministratorTIME COMPLETED:
05:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Jessica Cho made a subsequent visit for the purpose to issue a citation after observing a deficiency while conducting a 10-day visit on May 30, 2023 in connection to 22-AS-20230524163541. LPA met with Administrator Jon Castro and explained the purpose of the case-management visit. The deficiency is as follows:

On May 30, 2023, LPA arrived at the facility and immediately observed upon entry at 11:23am that the metal hinge to the medication cabinet was broken. LPA opened the medication cabinet and observed the clients’ medications were unsecured and accessible. Staff #1 (S1) and Staff #2 (S2) were made aware during the inspection. Per S1, management was notified on May 29, 2023 that the hinge was broken. On the same date, at 12:35pm, LPA observed Admin Castro repairing the broken hinge with a screw gun and was corrected during the visit.

Therefore, based on LPA's observations, a deficiency is being cited as per Title 22, Division 6, Chapter 1 of the California Code of Regulations. See the attached LIC809-D.

An exit interview was conducted with Administrator Jon Castro, and a copy of this report including the LIC809-D were provided during today’s visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2023
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 08/03/2023 05:24 PM - It Cannot Be Edited


Created By: Jessica Cho On 08/03/2023 at 05:08 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: 08/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/04/2023
Section Cited
CCR
80075(k)(1)

1
2
3
4
5
6
7
80075 Health Related Services (k) The following requirements shall apply to medications which are centrally stored:
(1) "Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible...".
1
2
3
4
5
6
7
Administrator to repair the broken hinge of the medication cabinet which was corrected during the visit and to submit a written Acknowledgement of Understanding to the said regulation to LPA via email by POC due date.
8
9
10
11
12
13
14
This requirement was not met as evidenced by: Based on LPA’s observations along with S1 and S2, the medications were unsecured and accessible on 05/30/2023 which poses an immediate Health, Safety, or 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.
SUPERVISOR'S NAME:Sheila Santos
LICENSING EVALUATOR NAME:Jessica Cho
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2