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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004295
Report Date: 05/30/2023
Date Signed: 05/30/2023 12:18:46 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
05/16/2023 and conducted by Evaluator Kimberly Lyman
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230516134040

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: 3DATE:
05/30/2023
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Paul ArcinasTIME COMPLETED:
12:50 PM
ALLEGATION(S):
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Facility staff hit residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility by Caregiver Paul Arcinas and explained the reason for the visit.
During the course of the investigation, LPA toured the facility and interviewed staff and clients. Regarding the allegation that facility staff hit residents, the investigation revealed the following. On 05/09/2023, facility reported Staff 3 threw a coloring book at Client 1 (C1) and hit the client in the face. Interviews conducted indicated C1 was hit on the eye lid with the book. No injuries were noted. Facility suspended S3 and facility administrator stated S3 would no longer be employed at the facility. Facility provided written proof of suspension to LPA and termination is pending. Based on the interviews conducted 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. Exit interview conducted and a copy of this report was provided to facility representative as well as appeal rights.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20230516134040
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: 05/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/31/2023
Section Cited
CCR
80072(a)(3)
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..each client shall have personal rights which include, but are not limited to, the following: To be free from corporal or unusual punishment, infliction of pain..., or other actions of a punitive nature...This requirement is not being met as evidenced by:
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Licensee to forward a written statement of understanding of the regulation to LPA by POC due date.
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Based on interviews conducted, Licensee failed to ensure clients are free from infliction of pain. S3 threw a coloring book at C1 and hit the clients eye lid. This poses an immediate 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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4