197602865-10-15-2024-28-AS-RORN-DA9UT2-20241021155109

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197602865
Report Date: 10/15/2024
Date Signed: 10/15/2024 10:51:03 AM

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
10/09/2024 and conducted by Evaluator Mary G Flores

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20241009095559

FACILITY NAME:	CHELLE'S HOME		FACILITY NUMBER:	197602865
ADMINISTRATOR:	PINEDA, ROMEO P.		FACILITY TYPE:	735
ADDRESS:	3234 ALAMEDA STREET		TELEPHONE:	(626) 568-0324
CITY:	PASADENA	STATE: CA	ZIP CODE:	91107
CAPACITY:	4	CENSUS: 2	DATE:	10/15/2024
		UNANNOUNCED	TIME BEGAN:	07:34 AM
MET WITH:	Millet Pineda - Administrator		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Facility staff are not qualified to provide care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation. LPA met with Millet Pineda and explained the reason for the visit.

The investigation consisted of the following: On 10/8/24 LPA Flores conducted interviews with clients #1-2(C1-C2) and staff #2(S2). On 10/15/24 LPA Flores conducted interview with administrator and client #3(C3) and requested copies of C1 and C3’s physician’s report, admission agreement, face sheet, individual program plan (IPP), psychological evaluation, and S2’s personnel record and trainings.

The investigation revealed the following: Regarding allegation: Facility staff are not qualified to provide care. It is alleged facility staff was not able to provide information regarding an incident and staff didn’t seem like they could provide care for the clients.
(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: 10/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20241009095559

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: 10/15/2024

NARRATIVE

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Interviews conducted revealed 1 out of 3 clients stated that a client has a behavior of hitting other clients. During lunch hour C2 “punch” C1 on the face upon C1 beginning to cry and C1 walked over their room and did not witness anything else. 2 out of 3 clients were unable to be interviewed due to cognitive skills. Interviews conducted with staff revealed, Staff #2(S2) was in the kitchen when C2 hit C1 in the face, C1 began to cry and S2 told C1 “Stop crying and go to your room” at least three times, as C1 becomes more upset. C1 walked around the kitchen and encounter C3 in the hallway and punch C3 as well. At that moment S2 intervene and held C3’s arm, as S2 held C3’s arm, C3 attempted to kick C1 and threw its body hitting own head in the door frame. S2 did not noticed at first. But minutes later noticed C3 was bleeding from the back of the head and called 911. Upon paramedics arriving at the facility, per S2 was too nervous to provide information of the incident to paramedics. A physical check was conducted on C1 and there were no marks or injuries noticed. Documents reviewed revealed clients have aggressive behaviors. S2 has the following training on file client’s rights dated 4/13/24, emotional awareness dated 3/23/24, effective staff communication dated 11/19/22, nonviolent crisis intervention training (CPI) dated 7/6/23, first aid training completed on 7/10/24, and direct support professional training competed on 12/3/21.

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: 10/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024

LIC9099 (FAS) - (06/04)

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