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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602865
Report Date: 10/08/2024
Date Signed: 10/08/2024 02:51:11 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/02/2024 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20241002083630
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:
10/08/2024
UNANNOUNCEDTIME BEGAN:
12:29 PM
MET WITH:Emma Gonzalez - CaregiverTIME COMPLETED:
03:05 PM
ALLEGATION(S):
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Facility staff slapped client
Facility staff pulled client's hair
Facility staff threw water on client
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Emma Gonzalez and explained the reason for the visit. Administrator arrived shortly after.

The investigation consisted of the following: LPA requested a copy of client and staff roster. LPA interviewed 3 staff and 2 clients. LPA reviewed client #1(C1)’s file and requested copies of physician’s report, individual program plan (IPP), needs and care plan, face sheet.

The investigation revealed the following: Regarding allegations: Facility staff slapped client, facility staff pulled client’s hair, and facility staff threw water on client. It is alleged administrator slapped C1 across the face, pulled C1’s hair and had thrown water on C1. Interviews with clients revealed 1 out of 2 clients stated that this was a one-time incident and that this was something that has not happened before.
(CONTINUED ON LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 28-AS-20241002083630
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/08/2024
NARRATIVE
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One (1) out of two (2) clients was not able to be interview due to cognitive skills. Interviews with staff revealed staff are respectful and do not hit or hurt the clients in any way. Administrator stated the incident did not happen and has never cause harm to the clients in care. LPA reviewed documents and there are no recent incident reports regarding the allegations. Staff have been provided personal rights training as part of their initial training and administrator received personal rights on April 13, 2024. Although the allegation may have happened there is not enough evidence to corroborate the allegation as the only people who can provide information about the incident are the two individuals involved.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted with Millet Pineda and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2