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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602865
Report Date: 10/25/2021
Date Signed: 10/25/2021 01:42:44 PM

Document Has Been Signed on 10/25/2021 01:42 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CHELLE'S HOMEFACILITY NUMBER:
197602865
ADMINISTRATOR:PINEDA, ROMEO P.FACILITY TYPE:
735
ADDRESS:3234 ALAMEDA STREETTELEPHONE:
(626) 568-0324
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 4CENSUS: DATE:
10/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:08 PM
MET WITH:Millet Pineda - LicenseeTIME COMPLETED:
03:30 PM
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual visit at the facility focus on the infection control domain, medication, and food. LPA met with Millet Pineda Licensee and explained the reason for the visit.

The facility is licensed to serve four(4), non-ambulatory, developmentally disabled adults, ages 18 to 59 years of age. The home is vendor through the Frank D. Lanterman Regional Center. Facility is a two story home. 2nd floor is not accessible to clients and it is a staff room. 1st floor consist of two share bedrooms, and one(1) client's bathroom, one (1) staff bathroom, a living room, dining room, kitchen, a front porch, a backyard, and two sheds. No large bodies of water observed.

LPA and Millet Pineda licensee conducted a tour of the facility and observed the following:
Living room has a screen cover fireplace. Smoke/Carbon Monoxide detectors were observed, tested and working. Kitchen facility has sufficient food supplies 2 days of perishables and 7 days of non-perishables. Sharps and Medication were observed locked in a cabinet in the kitchen. Cleaning supplies are kept locked under sink. Fire extinguisher observed in laundry wall. Both bedrooms have sufficient lighting, and required bedding/furniture. Bathrooms were observed in working condition and water was tested in bathroom #1 at 107.2 and bathroom #2 at 106.7 degrees F which is under the required 105 - 120 degrees F. LPA observed PPE supplies in outside shed. LPA reviewed clients' #1(C1), #2(C2), and #3(C3) medication. Romeo Pineda Certificate #6015656735 exp. date: 5/6/22 Millet Pineda Certificate #6013451735 exp. date: 2/18/22.

Facility is following COVID 19 recommendations in regards to signs throughout the facility, screening visitors, staff, and clients, and visitation. Cleaning and disinfecting procedures are conducted daily. Staff are in need of N95 Fit testing. Facility has at least 30 days of PPE supplies.
No deficiencies were given during this visit. Exit interview was conducted with Millet Pineda Licensee and a copy of this report and technical advisory note was given.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2021
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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