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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602865
Report Date: 07/12/2022
Date Signed: 07/12/2022 03:30:55 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/12/2022 03:30 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: 3DATE:
07/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Ramiro Martinez - Caregiver TIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on infection control, food review, and medication review. LPA met with Ramiro Martinez - Caregiver and explain 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 and observed the following:
Kitchen - sharps, medication and disinfecting supplies were under lock in cabinet located in kitchen area. Refrigerator was empty, however perishables were observed in garage's refrigerator and non-perishables in pantry sufficient. Client's bathroom was observed and water temperature was measured at 112.1 degrees F., which is within the required 105-120 degrees F, a roach was observed in the wall. Client bedrooms #1 and #2 were observed and bed bug was observed in Client #1's bed and Client #3 bed. Smoke detector was tested and in working condition. Fire Extinguisher was observed and fully charged.
Facility is screening visitors, visitation rights were reviewed with staff. Screening is conducted with clients and staff. Signs are posted throughout the facility. Hand washing sign was not observed in client's bathroom, paper towels not available due to client's cognitive skills per staff. Staff have not been Fit tested for N95, PPE was observed but it is not sufficient for 30 days.

Exit interview was conducted with R. Martinez a copy provided.
Deficiencies were given under Title 22 Regulations:

*LPA Flores was experiencing technical difficulties during the visit . This report is a copy of the manual copy report provided which will be place on the facility's file with signature.*
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2022
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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Document Has Been Signed on 07/12/2022 03:30 PM - It Cannot Be Edited


Created By: Mary G Flores On 07/12/2022 at 02:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CHELLE'S HOME
FACILITY NUMBER: 197602865

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/13/2022
Section Cited
CCR
80087(a)(1)

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80087 Buildings and Grounds: (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
(1) The licensee shall take measures to keep the facility free of flies and other insects.
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Administrator is to submit contract with exterminator company by POC due date.
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Based on observation licensee failed to maintain the facility free of roaches and bedbugs which is an immediate risk safety, health, or personal rights to clients in care.
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Type B
07/26/2022
Section Cited
CCR85064(j)(5)

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85064 Administrator Qualifications and Duties: (j) The administrator shall perform the following duties: (5) Arrangement for special provisions for the care and supervision and safety and guidance of clients...
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Administrator is to submit results of N95 fit test by POC due date.
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Based on interview licensee failed to provide N95 Fit testing for staff, health, and personal rights for clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stefanie Coronel
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2022


LIC809 (FAS) - (06/04)
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