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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602865
Report Date: 07/23/2024
Date Signed: 07/23/2024 03:06:59 PM

Document Has Been Signed on 07/23/2024 03:06 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/
DIRECTOR:		PINEDA, ROMEO P.FACILITY TYPE:
735
ADDRESS:3234 ALAMEDA STREETTELEPHONE:
(626) 568-0324
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 4CENSUS: 3DATE:
07/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:44 PM
MET WITH:Millet Pineda - LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual inspection visit at the facility using the CARE inspection tool. LPA met with Millet Pineda 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 pantry, basement, a detached garage, a front, and outdoor cover area, and back yard.

LPA Flores conducted a tour of the facility with Millet Pineda and observed the following:
Facility is in good repair indoor and outdoors. All common areas are clean and in good repair with sufficient furniture. Living room has a fireplace that is covered. Kitchen is clean, food supplies were observed and are sufficient for at least 2 days of perishables and 7 days of non-perishables. Medication cabinet was observed locked. Sharps and cleaning supplies were observed locked. First aid kit was observed. Two resident rooms were observed with sufficient lighting, furniture and the required bedding supplies. Two bathrooms were observed clean and in good repair, water temperature was tested between 116.9 - 117.1 degrees F. which is within the required 105-120 degrees F. Smoke/Carbon monoxide detectors were tested and are in working condition. Fire extinguisher was observed in the wall in the laundry area. Laundry area was observed in good repair. A covered outdoor area was observed with furniture. Basement is not accessible to the clients. Passageways and outdoor area is clean and free of debris.

LPA reviewed medication, files, and P&I money for three residents and four staff files. Interviews were conducted with 1 client and 1 staff.

Infection control and Emergency Disaster plans were reviewed and were last reviewed on 7/21/24. Last emergency drill was conducted on 7/7/24. (CONTINUED ON LIC 809C)
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 197602865
VISIT DATE: 07/23/2024
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Administrator certificate was observed for Millet Pineda #6013451735 exp. date:2/18/24 renewed documents were submitted to the department on 1/19/24, application is still pending.

During this visit Licensee notified LPA that the phone number has been change. Licensee will submit a letter to the department for phone number change update/request.

No Deficiencies noted 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: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC809 (FAS) - (06/04)
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