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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602865
Report Date: 07/13/2023
Date Signed: 07/13/2023 03:21:36 PM

Document Has Been Signed on 07/13/2023 03:21 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
GREATER LA AC/SC, 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: 3DATE:
07/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:53 PM
MET WITH:Millet Pineda - AdministratorTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE tool. LPA met with Millet Pineda Administrator and explained the reason for the visit.

The facility is licensed to serve 4 non-ambulatory developmentally disable adults ages 18 to 59 years of age. Facility is a single home, in a residential neighborhood, with a kitchen, living room , dining room, 2 client bedrooms, a client bathroom, a staff bathroom, a laundry room, a detached garage, a front, and outdoor cover area, and back yard.

LPA conducted a tour of the facility with Millet Pineda and observed the following:
Facility is in good repair inside and outside. Living room has a covered fireplace, Kitchen area stores medication and sharps in a cabinet. Cleaning supplies are stored under the sink and kept lock. Non-perishables were observed in the pantry sufficient for at least 7 days and perishables for at least 2 days. Client's bedrooms were observed with the required furniture and sufficient bedding/lighting. Two (2) facility bathrooms' were observed to be in working condition and water temperature was tested at 107.0 degrees F., in both. Covered shaded patio in the backyard has seating area. Smoke/Carbon detectors were observed and are in working condition. Last Fire drill was conducted on 5/1/23. Fire extinguishers were last checked on 10/7/22.

LPA reviewed 3 client files, medication, and P&I money and 5 staff files. Administrator certificate was observed for Millet Pineda #6013451735 exp: 2/18/24.

No deficiencies cited during this visit.

Exit interview was conducted with Millet Pineda and a copy of this report was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2023
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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